Dental Certificate Template by ffu73503

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									United HealthCare Insurance Company


        UNITED HEALTHCARE
                 PPO Dental
       Certificate of Coverage

     FOR: The School District of Palm Beach County
            DENTAL PLAN NUMBER: P5215
         ENROLLING GROUP NUMBER: 704471
           EFFECTIVE DATE: January 1, 2010




              Offered and Underwritten by
         United HealthCare Insurance Company
                United HealthCare Insurance Company
                         Dental Certificate of Coverage
This Certificate of Coverage ("Certificate") sets forth your rights and obligations as a Covered Person. It is
important that you READ YOUR CERTIFICATE CAREFULLY and familiarize yourself with its terms and
conditions.
The Policy may require that the Subscriber contribute to the required Premiums. Information regarding
the Premium and any portion of the Premium cost a Subscriber must pay can be obtained from the
Enrolling Group.
United HealthCare Insurance Company ("Company") agrees with the Enrolling Group to provide
Coverage for Dental Services to Covered Persons, subject to the terms, conditions, exclusions and
limitations of the Policy. The Policy is issued on the basis of the Enrolling Group's application and
payment of the required Policy Charges. The Enrolling Group's application is made a part of the Policy.
The Company will not be deemed or construed as an employer for any purpose with respect to the
administration or provision of benefits under the Enrolling Group's benefit plan. The Company will not be
responsible for fulfilling any duties or obligations of an employer with respect to the Enrolling Group's
benefit plan.

          This Policy Contains a Deductible Provision
The Policy will take effect on the date specified in the Policy and will be continued in force by the timely
payment of the required Policy Charges when due, subject to termination of the Policy as provided. All
Coverage under the Policy will begin at 12:01 a.m. and end at 12:00 midnight at the Enrolling Group's
address.
The Policy is delivered in and governed by the laws of the State of Florida.




DCOC.CER.06.FL                                        1
                       Introduction to Your Certificate
You and any of your Enrolled Dependents, are eligible for Coverage under the Policy if the required
Premiums have been paid. The Policy is referred to in this Certificate as the "Policy" and is designated on
the identification ("ID") card.
Coverage is subject to the terms, conditions, exclusions, and limitations of the Policy. As a Certificate, this
document describes the provisions of Coverage under the Policy but does not constitute the Policy. You
may examine the entire Policy at the office of the Enrolling Group during regular business hours.
For Dental Services rendered after the effective date of the Policy, this Certificate replaces and
supersedes any Certificate, which may have been previously issued to you by the Company. Any
subsequent Certificates issued to you by the Company will in turn supersede this Certificate.
The employer expects to continue the group plan indefinitely. But the employer reserves the right to
change or end it at any time. This would change or end the terms of the Policy in effect at that time for
active or retired employees.


How To Use This Certificate
This Certificate should be read and re-read in its entirety. Many of the provisions of this Certificate and
the attached Schedule of Covered Dental Services are interrelated; therefore, reading just one or two
provisions may not give you an accurate impression of your Coverage.
Your Certificate and Schedule of Covered Dental Services may be modified by the attachment of Riders
and/or Amendments. Please read the provision described in these documents to determine the way in
which provisions in this Certificate or Schedule of Covered Dental Services may have been changed.
Many words used in this Certificate and Schedule of Covered Dental Services have special meanings.
These words will appear capitalized and are defined for you in Section 1: Definitions. By reviewing these
definitions, you will have a clearer understanding of your Certificate and Schedule of Covered Dental
Services.
When we use the words "we," "us," and "our" in this document, we are referring to United HealthCare
Insurance Company. When we use the words "you" and "your" we are referring to people who are
Covered Persons as the term is defined in Section 1: Definitions.
From time to time, the Policy may be amended. When that happens, a new Certificate, Schedule of
Covered Dental Services or Amendment pages for this Certificate or Schedule of Covered Dental
Services will be sent to you. Your Certificate and Schedule of Covered Dental Services should be kept in
a safe place for your future reference.


Network and Non-Network Benefits
This Certificate describes both benefit levels available under the Policy.
Network Benefits - These benefits apply when you choose to obtain Dental Services from a Network
Dentist. Section 10: Procedures for Obtaining Benefits describes the procedures for obtaining Covered
Dental Services as Network Benefits. Unless otherwise noted in the Schedule of Covered Dental Services
or Section 11: Covered Dental Services, Network Benefits are subject to payment of any Deductible and
any applicable Waiting Period and generally require you to pay less to the provider than Non-Network
Benefits. Network Benefits are determined based on the contracted fee for each Covered Dental Service.
In no event, will you be required to pay a Network Dentist an amount for a Covered Dental Service in
excess of the contracted fee.
Non-Network Benefits - These benefits apply when you decide to obtain Dental Services from Non-
Network Dentists. Section 10: Procedures for Obtaining Benefits describes the procedures for obtaining

DCOC.INT.06                                           2
Covered Dental Services as Non-Network Benefits. Unless otherwise noted in the Schedule of Covered
Dental Services or Section 11: Covered Dental Services, Non-Network Benefits are subject to a
Deductible and generally require you to pay more than Network Benefits. Non-Network Benefits are
determined based on the Usual and Customary fee for similarly situated Network Dentists for each
Covered Dental Service. The actual charge made by a Non-Network Dentist for a Covered Dental Service
may exceed the Usual and Customary fee. As a result, you may be required to pay a Non-Network
Dentist an amount for a Covered Dental Service in excess of the Usual and Customary fee. In addition,
when you obtain Covered Dental Services from Non-Network Dentists, you must file a claim with the
Company to be reimbursed for Eligible Expenses.
The information in Section 1: Definitions through Section 9: Continuation of Coverage applies to both
levels of Coverage. Section 10: Procedures for Obtaining Benefits, the Schedule of Covered Dental
Services and Section 11: Covered Dental Services explain the procedures you must follow to obtain
Coverage for Network Benefits and Non-Network Benefits. The Schedule of Covered Dental Services or
Section 11: Covered Dental Services describe which Dental Services are Covered. Unless otherwise
specified, the exclusions and limitations that appear in Section 12: General Exclusions apply to both
levels of benefits. The Schedule of Covered Dental Services or Section 11: Covered Dental Services
describe what Copayments are required, if any, and to what extent any limitations apply.


Dental Services Covered Under the Policy
In order for Dental Services to be Covered as Network Benefits, you must obtain all Dental Services
directly from or through a Network Dentist.
You must always verify the participation status of a provider prior to seeking services. From time to time,
the participation status of a provider may change. You can verify the participation status by calling the
Company and/or provider. If necessary, the Company can provide assistance in referring you to Network
Dentists. If you use a provider that is not a participating provider, you will be required to pay the entire bill
for the services you received.
Only Necessary Dental Services are Covered under the Policy. The fact that a Dentist has performed or
prescribed a procedure or treatment, or the fact that it may be the only available treatment, for a dental
disease does not mean that the procedure or treatment is Covered under the Policy.
The Company has sole and exclusive discretion in interpreting the benefits Covered under the Policy and
the other terms, conditions, limitations and exclusions set out in the Policy and in making factual
determinations related to the Policy and its benefits. The Company may, from time to time, delegate
discretionary authority to other persons or entities providing services in regard to the Policy.
The Company reserves the right to change, interpret, modify, withdraw or add benefits or terminate the
Policy, in its sole discretion, as permitted by law, without the approval of Covered Persons. No person or
entity has any authority to make any oral changes or amendments to the Policy.
The Company may, in certain circumstances for purposes of overall cost savings or efficiency and in its
sole discretion, provide Coverage for services, which would otherwise not be Covered. The fact that the
Company does so in any particular case will not in any way be deemed to require it to do so in other
similar cases.
The Company may, in its sole discretion, arrange for various persons or entities to provide administrative
services in regard to the Policy, including claims processing and utilization management services. The
identity of the service providers and the nature of the services provided may be changed from time to time
in the Company's sole discretion and without prior notice to or approval by Covered Persons. You must
cooperate with those persons or entities in the performance of their responsibilities.
Similarly, the Company may, from time to time, require additional information from you to verify your
eligibility or your right to receive Coverage for services under the Policy. You are obligated to provide this
information. Failure to provide required information may result in Coverage being delayed or denied.



DCOC.INT.06                                             3
Important Note About Services
The Company does not provide Dental Services or practice dentistry. Rather, the Company arranges for
providers of Dental Services to participate in a Network. Network Dentists are independent practitioners
and are not employees of the Company. The Company, therefore, makes payment to Network Dentists
through various types of contractual arrangements. These arrangements may include financial incentives
to promote the delivery of dental care in a cost efficient and effective manner. Such financial incentives
are not intended to impact your access to Necessary Dental Services.
The payment methods used to pay any specific Network Dentist vary. The method may also change at
the time providers renew their contracts with the Company. If you have questions about whether there are
any financial incentives in your Network Dentist's contract with the Company, please contact the
Company at the telephone number on your ID card. The Company can advise you whether your Network
Dentist is paid by any financial incentive, however, the specific terms, including rates of payment, are
confidential and cannot be disclosed.
The Dentist-patient relationship is between you and your Dentist. This means that:

•     You are responsible for choosing your own Dentist.

•     You must decide if any Dentist treating you is right for you. This includes Network Dentists who you
      choose or providers to whom you have been referred.

•     You must decide with your Dentist what care you should receive.

•     Your Dentist is solely responsible for the quality of the care you receive.
The Company makes decisions about eligibility and if a benefit is a Covered benefit under the Policy.
These decisions are administrative decisions. The Company is not liable for any act or omission of a
provider of Dental Services.


Important Information Regarding Medicare
Coverage under the Policy is not intended to supplement any coverage provided by Medicare, but in
some circumstances Covered Persons who are eligible for or enrolled in Medicare may also be enrolled
for Coverage under the Policy. If you are eligible for or enrolled in Medicare, please read the following
information carefully.
If you are eligible for Medicare, you must enroll for and maintain coverage under both Medicare Part A
and Part B. If you don't enroll, and if the Company is the secondary payer as described in Section 7:
Coordination of Benefits of this Certificate, the Company will pay benefits under the Policy as if you were
covered under both Medicare Part A and Part B and you will incur a larger out of pocket cost for Health
Services.
If, in addition to being enrolled for Coverage under the Policy, you are enrolled in a Medicare Advantage
(Medicare Part C) plan, you must follow all rules of that plan that require you to seek services from that
plan's participating providers. When the Company is the secondary payer, we will pay any benefits
available to you under the Policy as if you had followed all rules of the Medicare Advantage plan. If the
Company is the secondary plan and you don't follow the rules of the Medicare Advantage plan, you will
incur a larger out of pocket cost for Dental Services.
If, in addition to being enrolled for Coverage under the Policy, you are enrolled in a Medicare Prescription
Drug (Medicare Part D) plan through either a Medicare Advantage plan with a prescription drug benefit
(MA-PD), a special-needs plan (SNP-PD) or a stand alone Prescription Drug Plan (PDP), you must follow
all rules of that plan that require you to seek services from that plan's participating pharmacies. When this
Company is the secondary payer, we will pay any benefits available to you under the Policy as if you had
followed all rules of the Medicare Part D plan. If this Company is the secondary plan and you don't follow
the rules of the Medicare Part D plan, you will incur a larger out of pocket cost for prescription drugs.


DCOC.INT.06                                           4
Identification ("ID") Card
You must show your ID card every time you request Dental Services. If you do not show your card, the
providers have no way of knowing that you are Covered under a Policy issued by the Company and you
may receive a bill for Network Benefits.


Contact the Company
Throughout this Certificate you will find statements that encourage you to contact the Company for further
information. Whenever you have a question or concern regarding Dental Services or any required
procedure, please contact the Company at the telephone number stated on your ID card.




DCOC.INT.06                                         5
     Dental Certificate of Coverage Table of Contents
Section 1: Definitions ............................................................................... 7
Section 2: Enrollment and Effective Date of Coverage ........................ 12
Section 3: Termination of Coverage ...................................................... 14
Section 4: Reimbursement ..................................................................... 16
Section 5: Complaint Procedures .......................................................... 18
Section 6: General Provisions ............................................................... 20
Section 7: Coordination of Benefits ...................................................... 23
Section 8: Subrogation and Refund of Expenses ................................ 28
Section 9: Continuation of Coverage .................................................... 30
Section 10: Procedures for Obtaining Benefits .................................... 33
Section 11: Covered Dental Services .................................................... 35
Section 12: General Exclusions ............................................................. 37




DCOC.TOC.06                                        6
                                 Section 1: Definitions
This Section defines the terms used throughout this Certificate and Schedule of Covered Dental Services
and is not intended to describe Covered or uncovered services.
Amendment - any attached description of additional or alternative provisions to the Policy. Amendments
are effective only when signed by an officer of the Company. Amendments are subject to all conditions,
limitations and exclusions of the Policy except for those which are specifically amended.
CDT Codes - mean the Current Dental Terminology for the current Code on Dental Procedures and
Nomenclature (the Code). The Code has been designated as the national standard for reporting dental
services by the Federal Government under the Health Insurance and Portability and Accountability Act of
1996 (HIPAA), and is currently recognized by third party payors nationwide.
Congenital Anomaly - a physical developmental defect that is present at birth and identified within the
first twelve months from birth.
Copayment - the charge you are required to pay for certain Dental Services payable under the Policy. A
Copayment may either be a defined dollar amount or a percentage of Eligible Expenses. You are
responsible for the payment of any Copayment for Network Benefits directly to the provider of the Dental
Service at the time of service or when billed by the provider.
Coverage or Covered - the entitlement by a Covered Person to reimbursement for expenses incurred for
Dental Services covered under the Policy, subject to the terms, conditions, limitations and exclusions of
the Policy. Dental Services must be provided: (1.) when the Policy is in effect; and (2.) prior to the date
that any of the individual termination conditions as stated in Section 3: Termination of Coverage occur;
and (3.) only when the recipient is a Covered Person and meets all eligibility requirements specified in the
Policy.
Covered Person – either the Subscriber or an Enrolled Dependent, while Coverage of such person
under the Policy is in effect. References to you and your throughout this Certificate are references to a
Covered Person.
Deductible – the amount a Covered Person must pay for Dental Services in a calendar year before the
Company will begin paying for Network or Non-Network Benefits in that calendar year.
Dental Service or Dental Procedures - dental care or treatment provided by a Dentist to a Covered
Person while the Policy is in effect, provided such care or treatment is recognized by the Company as a
generally accepted form of care or treatment according to prevailing standards of dental practice.
Dentist - any dental practitioner who is duly licensed and qualified under the law of jurisdiction in which
treatment is received to render Dental Services, perform dental surgery or administer anesthetics for
dental surgery.
Dependent - (1.) the Subscriber's legal spouse. All references to the spouse of a Subscriber shall include
a Domestic Partner, or (2.) a dependent child of the Subscriber or the Subscriber's spouse (including a
natural child, stepchild, a legally adopted child, a child placed for adoption, or a child for whom legal
guardianship has been awarded to the Subscriber or the Subscriber's spouse). The term child also
includes a grandchild of either the Subscriber or the Subscriber's spouse. To be eligible for coverage
under the Policy, a Dependent must reside within the United States. The definition of Dependent is
subject to the following conditions and limitations:
The Dependent child will be covered until the end of the calendar year in which the child reaches the age
of 25, if the child meets all of the following:

•     The child is dependent upon the Subscriber for support.

•     The child is living in the household of the Subscriber, or the child is a Full-time or part-time student.


DCOC.DEF.06.FL                                        7
The Subscriber agrees to reimburse the Company for any Dental Services provided to the child at a time
when the child did not satisfy these conditions.
The term Dependent also includes a child for whom dental care coverage is required through a Qualified
Medical Child Support Order or other court or administrative order. The Enrolling Group is responsible for
determining if an order meets the criteria of a Qualified Medical Child Support Order.
The term Dependent does not include anyone who is also enrolled as a Subscriber, nor can anyone be a
Dependent of more than one Subscriber.
Domestic Partner - a person of the opposite or same sex with whom the Subscriber has established a
Domestic Partnership. In no event, will a person's legal spouse be considered a Domestic Partner.
Domestic Partnership - a relationship between the Subscriber and one other person of the opposite or
same sex. The following requirements apply to both persons:

•     They share the same permanent residence and the common necessities of life;

•     They are not related by blood or a degree of closeness which would prohibit marriage in the law of
      state in which they reside;

•     Each is at least 18 years of age;

•     Each is mentally competent to consent to contract;

•     Neither is currently married to, or Domestic Partner of, another person under either a statutory or
      common law;

•     They are financially interdependent and have furnished at least two of the following documents
      evidencing such financial interdependence:
            have a single dedicated relationship of at least 6 months duration;
            joint ownership of residence;
            at least two of the following:
             ♦      joint ownership of an automobile;
             ♦      joint checking, bank or investment account;
             ♦      joint credit account;
             ♦      lease for a residence identifying both partners as tenants;
             ♦      a will and/or life insurance policies which designates the other as primary beneficiary.

•     The Subscriber and Domestic Partner must jointly sign an affidavit of Domestic Partnership.
Eligible Expenses – Eligible Expenses for Covered Dental Services, incurred while the Policy is in effect,
are determined as stated below:
A.    For Network Benefits, when Covered Dental Services are received from Network Dentists, Eligible
      Expenses are the Company's contracted fee(s) for Covered Dental Services with that provider.
B.    For Non-Network Benefits, when Covered Dental Services are received from Non-Network
      Dentists, Eligible Expenses are the Usual and Customary fees as defined below.
In the event that a provider routinely waives Copayments and/or the Deductible, Dental Services for
which the Copayments and/or the Deductible are waived are not considered to be Eligible Expenses.
Eligible Person - an employee of the Enrolling Group or other person whose connection with the
Enrolling Group meets the eligibility requirements specified in both the application and the Policy.

DCOC.DEF.06.FL                                       8
Emergency - a dental condition or symptom resulting from dental disease which arises suddenly and, in
the judgment of a reasonable person, requires immediate care and treatment, and such treatment is
sought or received within 24 hours of onset.
Enrolled Dependent - a Dependent who is properly enrolled for Coverage under the Policy.
Enrolling Group - the employer or other defined or otherwise legally constituted group to whom the
Policy is issued.
Experimental, Investigational or Unproven Services - medical, dental, surgical, diagnostic, or other
health care services, technologies, supplies, treatments, procedures, drug therapies or devices that, at
the time the Company makes a determination regarding coverage in a particular case, is determined to
be:
A.    Not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the
      proposed use and not identified in the American Hospital Formulary Service or the United States
      Pharmacopoeia Dispensing Information as appropriate for the proposed use; or
B.    Subject to review and approval by any institutional review board for the proposed use; or
C.    The subject of an ongoing clinical trial that meets the definition of a Phase 1, 2 or 3 clinical trial set
      forth in the FDA regulations, regardless of whether the trial is actually subject to FDA oversight; or
D.    Not demonstrated through prevailing peer-reviewed professional literature to be safe and effective
      for treating or diagnosing the condition or illness for which its use is proposed.
Foreign Services - are defined as services provided outside the U.S. and U.S. territories.
Full-time Student - a person who is enrolled in and attending, full-time, a recognized course of study or
training at:
A.    An accredited high school;
B.    An accredited college or university; or
C.    A licensed vocational school, technical school, beautician school, automotive school or similar
      training school.
Full-time Student status is determined in accordance with the standards set forth by the educational
institution. A person ceases to be a Full-time Student at the end of the calendar year during which the
person graduates or otherwise ceases to be enrolled and in attendance at the institution on a full-time
basis.
A person continues to be a Full-time Student during periods of regular vacation established by the
institution. If the person does not continue as a Full-time Student immediately following the period of
vacation, the Full-time Student designation will end on the last day of the calendar year in which the
person was enrolled and in attendance at the institution on a full-time basis.
Initial Eligibility Period - the initial period of time, determined by the Company and the Enrolling Group,
during which Eligible Persons may enroll themselves and Dependents under the Policy.
Maximum Benefit – the maximum amount paid for Covered Dental Services during a calendar year for a
Covered Person under the Policy or any Policy, issued by the Company to the Enrolling Group, that
replaces the Policy. The Maximum Benefit is stated in Section 11: Covered Dental Services.
Maximum Policy Benefit - the maximum amount paid for Network and Non-Network Benefits during the
entire period of time that the Covered Person is Covered under the Policy or any Policy, issued by the
Company to the Enrolling Group, that replaces the Policy. The Maximum Policy Benefit is stated in
Section 11: Covered Dental Services.




DCOC.DEF.06.FL                                         9
Medicare – Parts A, B, C, and D of the insurance program established by Title XVIII, United States Social
Security Act, as amended by 42 U.S.C. Sections 1394, et seq. and as later amended.
Necessary - Dental Services and supplies which are determined by the Company through case-by-case
assessments of care based on accepted dental practices to be appropriate; and
A.    necessary to meet the basic dental needs of the Covered Person; and
B.    rendered in the most cost-efficient manner and type of setting appropriate for the delivery of the
      Dental Service; and
C.    consistent in type, frequency and duration of treatment with scientifically based guidelines of
      national clinical, research, or health care coverage organizations or governmental agencies that
      are accepted by the Company; and
D.    consistent with the diagnosis of the condition; and
E.    required for reasons other than the convenience of the Covered Person or his or her Dentist; and
F.    demonstrated through prevailing peer-reviewed dental literature to be either:
      1.     safe and effective for treating or diagnosing the condition or sickness for which their use is
             proposed; or
      2.     safe with promising efficacy
             a.     for treating a life threatening dental disease or condition; and
             b.     in a clinically controlled research setting; and
             c.     using a specific research protocol that meets standards equivalent to those defined by
                    the National Institutes of Health.
(For the purpose of this definition, the term life threatening is used to describe dental diseases or
sicknesses or conditions, which are more likely than not to cause death within one year of the date of the
request for treatment.)
The fact that a Dentist has performed or prescribed a procedure or treatment or the fact that it may be the
only treatment for a particular dental disease does not mean that it is a Necessary Covered Dental
Service as defined in this Certificate. The definition of Necessary used in this Certificate relates only to
Coverage and differs from the way in which a Dentist engaged in the practice of dentistry may define
necessary.
Network - a group of Dentists who are subject to a participation agreement in effect with the Company,
directly or through another entity, to provide Dental Services to Covered Persons. The participation status
of providers will change from time to time.
Network Benefits - benefits available for Covered Dental Services when provided by a Dentist who is a
Network Dentist.
Non-Network Benefits - coverage available for Dental Services obtained from Non-Network Dentists.
Open Enrollment Period - after the Initial Eligibility Period, a period of time determined by the Company
and the Enrolling Group, during which Eligible Persons may enroll themselves and Dependents under the
Policy.
Physician - any Doctor of Medicine, M.D., or Doctor of Osteopathy, D.O., who is duly licensed and
qualified under the law of jurisdiction in which treatment is received.
Plan Allowance - is shown as a fixed dollar amount or percentage of Eligible Expenses after the
Deductible is satisfied and is the maximum benefit amount the Company will pay for each particular



DCOC.DEF.06.FL                                        10
Dental Procedure shown. The Subscriber must pay the amount of the Dentist's fee, if any, which is
greater than the amount of the Plan Allowance.
Policy - the group Policy, the application of the Enrolling Group, Amendments and Riders which
constitute the agreement regarding the benefits, exclusions and other conditions between the Company
and the Enrolling Group.
Policy Charge - the sum of the Premiums for all Subscribers and Enrolled Dependents Covered under
the Policy.
Premium - the periodic fee required for each Subscriber and each Enrolled Dependent in accordance
with the terms of the Policy.
Procedure in Progress - all treatment for Covered Dental Services that results from a recommendation
and an exam by a Dentist. A treatment procedure will be considered to start on the date it is initiated and
will end when the treatment is completed.
Rider - any attached description of Dental Services Covered under the Policy. Dental Services provided
by a Rider may be subject to payment of additional Premiums and additional Copayments. Riders are
effective only when signed by an officer of the Company and are subject to all conditions, limitations and
exclusions of the Policy except for those that are specifically amended.
Subscriber - an Eligible Person who is properly enrolled for Coverage under the Policy. The Subscriber
is the person (who is not a Dependent) on whose behalf the Policy is issued to the Enrolling Group.
Usual and Customary - Usual and Customary fees are calculated by the Company based on available
data resources of competitive fees in that geographic area.
Usual and Customary fees must not exceed the fees that the provider would charge any similarly situated
payor for the same services. In the event that a provider routinely waives Copayments and/or the
Deductible for benefits, Dental Services for which the Copayments and/or the Deductible are waived are
not considered to be Usual and Customary.
Usual and Customary fees are determined solely in accordance with the Company's reimbursement
policy guidelines. The Company's reimbursement policy guidelines are developed by the Company, in its
discretion, following evaluation and validation of all provider billings in accordance with one or more of the
following methodologies:

•     As indicated in the most recent edition of the Current Procedural Terminology (publication of the
      American Dental Association);

•     As reported by generally recognized professionals or publications;

•     As utilized for Medicare;

•     As determined by medical or dental staff and outside medical or dental consultants;

•     Pursuant to other appropriate source or determination accepted by the Company.
Waiting Period - period of time for which a Covered Person must wait, after the effective date of
Coverage, before Dental Services listed in Section 11: Covered Dental Services will be Covered.




DCOC.DEF.06.FL                                       11
 Section 2: Enrollment and Effective Date of Coverage
Section 2.1 Enrollment
Eligible Persons may enroll themselves and their Dependents for Coverage under the Policy during the
Initial Eligibility Period or during an Open Enrollment Period by submitting a form provided or approved by
the Company. In addition, new Eligible Persons and new Dependents may be enrolled as described
below. Dependents of an Eligible Person may not be enrolled unless the Eligible Person is also enrolled
for Coverage under the Policy.
If you enroll for Coverage under the Policy, you must remain enrolled for a period of 12 months. If you
disenroll at the end of any 12 month period, you must wait 12 months until you are again eligible for
Coverage.
If both spouses are Eligible Persons of the Enrolling Group, each may enroll as a Subscriber or be
covered as an eligible Dependent of the other, but not both. If both parents of an eligible Dependent child
are enrolled as a Subscriber, only one parent may enroll the child as a Dependent.
If you fail to enroll yourself or a Dependent during the Initial Eligibility Period or during an Open
Enrollment Period, you or your Dependent must wait 12 months before you or your Dependent is eligible
to enroll for Dental benefits.


Section 2.2 Effective Date of Coverage
In no event is there Coverage for Dental Services rendered or delivered before the effective date of
Coverage.
If an Eligible Person enrolls during the Initial Eligibility Period, Coverage is effective on the first day of the
policy month following the month in which the probationary period was completed.


Section 2.3 Coverage for a Newly Eligible Person
Coverage for you and any of your Dependents will take effect on the date agreed to by the Enrolling
Group and the Company. Coverage is effective only if the Company receives any required Premium and
a properly completed enrollment form within 31 days of the date you first become eligible.


Section 2.4 Coverage for a Newly Eligible Dependent
Coverage for a new Dependent acquired by reason of birth, legal adoption, legal guardianship, placement
for adoption or of a foster child, court or administrative order, or marriage will take effect on the date of
the event.
Coverage is effective only if the Company receives any required Premium and is notified of the event
within 31 days, except in the case of newborn or adopted children.
Coverage For Newborn Children
All dental benefits applicable for children, including the Necessary care or treatment of medically
diagnosed congenital defects or birth abnormalities, will apply with respect to your or your insured
Dependent’s newborn child from the moment of birth.
However, the Coverage for your insured Dependent’s newborn child terminates 18 months after the birth
of the newborn child.




DCOC.ENR.06.FL                                     12
You must give us written notice within 30 days of the child’s birth. If timely notice is given, we will not
charge an additional premium for coverage of the newborn child for the duration of the notice period. If
timely notice is not given, we will charge the applicable additional premium from the date of birth. If notice
is given within 60 days of the birth of the child, we will not deny coverage for the child due to your failure
to timely notify us of the child’s birth.


Coverage for Adopted Children
All dental benefits applicable to children will apply to your adopted child or foster child or other child in
your court-ordered custody, from the moment of placement in your residence.
In the case of a newborn child, coverage begins at the moment of birth if you have entered into a written
agreement to adopt such child, whether or not the agreement is enforceable.
You must give us written notice within 30 days of the child’s birth or placement. If timely notice is given,
we will not charge an additional premium for coverage of the newborn child for the duration of the notice
period. If timely notice is not given, we will charge the applicable additional premium from the date of
birth or placement. If notice is given within 60 days of the birth or placement of the child, we will not deny
coverage for the child due to your failure to timely notify us of the child’s birth or placement.


Section 2.5 Change in Family Status
You may make Coverage changes during the year for any Dependent whose status as a Dependent is
affected by a marriage, divorce, legal separation, annulment, birth, legal guardianship, placement for
adoption or adoption, as required by federal law. In such cases you must submit the required contribution
of coverage and a properly completed enrollment form within 31 days of the marriage, birth, placement for
adoption or adoption. Otherwise, you will need to wait until the next annual Open Enrollment Period.


Section 2.6 Special Enrollment Period
An Eligible Person and/or Dependent who did not enroll for Coverage under the Policy during the Initial
Eligibility Period or Open Enrollment Period may enroll for Coverage during a special enrollment period. A
special enrollment period is available if the following conditions are met: (a.) the Eligible Person and/or
Dependent had existing health coverage under another plan at the time of the Initial Eligibility Period or
Open Enrollment Period; and (b.) Coverage under the prior plan was terminated as a result of loss of
eligibility (including, without limitation, legal separation, divorce or death), termination of employer
contributions, or in the case of COBRA continuation coverage, the coverage was exhausted. A special
enrollment period is not available if coverage under the prior plan was terminated for cause or as a result
of failure to pay Premiums on a timely basis. Coverage under the Policy is effective only if the Company
receives any required Premium and a properly completed enrollment form within 31 days of the date
coverage under the prior plan terminated. A special enrollment period is also available for an Eligible
Person and for any Dependent whose status as a Dependent is affected by a marriage, birth, placement
for adoption or adoption, as required by federal law. In such cases you must submit the required Premium
and a properly completed enrollment form within 31 days of the marriage, birth, placement for adoption or
adoption.




DCOC.ENR.06.FL                                     13
                   Section 3: Termination of Coverage
Section 3.1 Conditions for Termination of a Covered Person's
Coverage Under the Policy
The Company may, at any time, discontinue this benefit plan and/or all similar benefit plans for the
reasons specified in the Policy. When your Coverage terminates, you may have continuation as
described in Section 9: Continuation of Coverage or as provided under other applicable federal and/or
state law.
Your Coverage, including coverage for Dental Services rendered after the date of termination for dental
conditions arising prior to the date of termination, will automatically terminate on the earliest of the dates
specified below.
A.    The date the entire Policy is terminated, as specified in the Policy. The Enrolling Group is
      responsible for notifying you of the termination of the Policy.
B.    The last day of the calendar month in which you cease to be eligible as a Subscriber or Enrolled
      Dependent.
C.    The date the Company receives written notice from either the Subscriber or the Enrolling Group
      instructing the Company to terminate Coverage of the Subscriber or any Covered Person or the
      date requested in such notice, if later.
D.    The date the Subscriber is retired or pensioned under the Enrolling Group's Plan, unless a specific
      Coverage classification is specified for retired or pensioned persons in the Enrolling Group's
      application and the Subscriber continues to meet any applicable eligibility requirements.
When any of the following apply, the Company will provide written notice of termination to the Subscriber.
E.    The date specified by the Company that all Coverage will terminate due to fraud or
      misrepresentation or because the Subscriber knowingly provided the Company with false material
      information, including, but not limited to, false, material information relating to residence,
      information relating to another person's eligibility for Coverage or status as a Dependent. The
      Company has the right to rescind Coverage back to the effective date.
F.    The date specified by the Company that all Coverage will terminate because the Subscriber
      permitted the use of his or her ID card by any unauthorized person or used another person's card.
G.    The date specified by the Company that Coverage will terminate due to material violation of the
      terms of the Policy.
H.    The date specified by the Company that your Coverage will terminate because you failed to pay a
      required Copayment.
I.    The date specified by the Company that your Coverage will terminate because you have committed
      acts of physical or verbal abuse which pose a threat to the Company staff, a provider, or other
      Covered Persons.


Section 3.2 Extended Coverage for Handicapped Dependent Children
Coverage of an unmarried Enrolled Dependent who is incapable of self-support because of mental
retardation or physical handicap will be continued beyond the age listed under the definition of Dependent
provided that:
A.    the Enrolled Dependent becomes incapacitated prior to attainment of the limiting age; and



DCOC.TER.06.FL                                    14
B.    the Enrolled Dependent is chiefly dependent upon the Subscriber for support and maintenance;
      and
C.    proof of such incapacity and dependence is furnished to the Company within 31 days of the date
      the Subscriber receives a request for such proof from the Company; and
D.    payment of any required Premium for the Enrolled Dependent is continued.
Coverage will be continued so long as the Enrolled Dependent continues to be so incapacitated and
dependent, unless otherwise terminated in accordance with the terms of the Policy. Before granting this
extension, the Company may reasonably require that the Enrolled Dependent be examined at the
Company's expense by a Physician designated by the Company. At reasonable intervals, the Company
may require satisfactory proof of the Enrolled Dependent's continued incapacity and dependency,
including medical examinations at the Company's expense. Such proof will not be required more often
than once a year. Failure to provide such satisfactory proof within 31 days of the request by the Company
will result in the termination of the Enrolled Dependent's Coverage under the Policy.


Section 3.3 Extended Benefits
If You or Your insured Dependent are in a course of treatment when coverage terminates, Dental
coverage will continue if all of the following apply:

•     the course of treatment or dental procedures were recommended in writing by Your or Your insured
      Dependent’s Doctor or Dentist while you were covered under the Plan;

•     the course of treatment or dental procedures commenced in connection with a specific Injury or
      Sickness incurred while You or Your insured Dependent were covered under the Plan; and

•     the termination of coverage did not occur as a result of Your voluntary termination of Your or Your
      insured Dependent’s coverage.
Extended Benefits do not apply to routine examinations, prophylaxis, X rays, sealants, or orthodontic
services.
Extended Benefits terminate upon the earlier of:

•     the end of the 90-day period after the coverage termination date; or

•     the date You or Your insured Dependent become covered by other dental insurance that provides
      coverage or services for similar dental procedures.
However, if the other dental insurance excludes the course of treatment or dental procedures through the
use of an elimination period, Extended Benefits do not terminate until the earlier of the end of the 90 day
period or the end of the elimination period.


Section 3.4 Payment and Reimbursement Upon Termination
Termination of Coverage will not affect any request for reimbursement of Eligible Expenses for Dental
Services rendered prior to the effective date of termination. Your request for reimbursement must be
furnished as required in Section 4: Reimbursement.




DCOC.TER.06.FL                                  15
                            Section 4: Reimbursement
Section 4.1 Reimbursement of Eligible Expenses
The Company will reimburse you for Eligible Expenses subject to the terms; conditions, exclusions and
limitations of the Policy and as described below.


Section 4.2 Filing Claims for Reimbursement of Eligible Expenses
You are responsible for sending a request for reimbursement to the Company's office, on a form provided
by or satisfactory to the Company. Requests for reimbursement should be submitted within 90 days after
date of service. Unless you are legally incapacitated, failure to provide this information to the Company
within 1 year of the date of service will cancel or reduce Coverage for the Dental Service.
Claim Forms. It is not necessary to include a claim form with the proof of loss. However, the proof must
include all of the following information:

•     Your name and address

•     Patient's name and age

•     Number stated on your ID card

•     The name and address of the provider of the service(s)

•     A diagnosis from the Dentist including a complete dental chart showing extractions, fillings or other
      dental services rendered before the charge was incurred for the claim

•     Radiographs, lab or hospital reports

•     Casts, molds or study models

•     Itemized bill which includes the CPT or ADA codes or description of each charge

•     The date the dental disease began

•     A statement indicating that you are or you are not enrolled for coverage under any other health or
      dental insurance plan or program. If you are enrolled for other coverage you must include the name
      of the other carrier(s).
If you would like to use a claim form, call the Company at the telephone number stated on your ID Card
and a claim form will be sent to you. If you do not receive the claim form within 15 days of your request,
send in the proof of loss with the information stated above.
Proof of Loss. Written proof of loss should be given to the Company within 90 days after the date of the
loss. If it was not reasonably possible to give written proof in the time required, the Company will not
reduce or deny the claim for this reason. However, proof must be filed as soon as reasonably possible,
but no later than 1 year after the date of service.
Payment of Claims. Benefits are payable in accordance with any state prompt pay requirements after
the Company receives acceptable proof of loss. Benefits will be paid to you unless:
A.    The provider notifies the Company that your signature is on file assigning benefits directly to that
      provider; or
B.    You make a written request at the time the claim is submitted.




DCOC.REM.06                                     16
Subject to written authorization from a Subscriber, all or a portion of any Eligible Expenses due may be
paid directly to the provider of the Dental Services instead of being paid to the Subscriber.


Section 4.3 Limitation of Action for Reimbursement
You do not have the right to bring any legal proceeding or action against the Company to recover
reimbursement until 90 days after you have properly submitted a request for reimbursement, as described
above. If you do not bring such legal proceeding or action against the Company within 5 years from the
date satisfactory written proof of loss was submitted to us, you forfeit your rights to bring any action
against the Company.




DCOC.REM.06                                     17
                      Section 5: Complaint Procedures
Section 5.1 Complaint Resolution
If you have a concern or question regarding the provision of Dental Services or benefits under the Policy,
you should contact the Company's customer service department at the telephone number shown on your
ID card. Customer service representatives are available to take your call during regular business hours,
Monday through Friday. At other times, you may leave a message on voicemail. A customer service
representative will return your call. If you would rather send your concern to us in writing at this point, the
Company's authorized representative can provide you with the appropriate address.
If the customer service representative cannot resolve the issue to your satisfaction over the phone, he or
she can provide you with the appropriate address to submit a written complaint. We will notify you of our
decision regarding your complaint within 30 days of receiving it.
If you disagree with our decision after having submitted a written complaint, you can ask us in writing to
formally reconsider your complaint. If your complaint relates to a claim for payment, your request should
include:

•     The patient's name and the identification number from the ID card

•     The date(s) of service(s)

•     The provider's name

•     The reason you believe the claim should be paid

•     Any new information to support your request for claim payment
We will notify you of our decision regarding our reconsideration of your complaint within 60 days of
receiving it. If you are not satisfied with our decision, you have the right to take your complaint to the
Office of the Commissioner of Insurance.


Section 5.2 Complaint Hearing
If you request a hearing, we will appoint a committee to resolve or recommend the resolution of your
complaint. If your complaint is related to clinical matters, the Company may consult with, or seek the
participation of, medical and/or dental experts as part of the complaint resolution process.
The committee will advise you of the date and place of your complaint hearing. The hearing will be held
within 60 days following receipt of your request by the Company, at which time the committee will review
testimony, explanation or other information that it decides is necessary for a fair review of the complaint.
We will send you written notification of the committee's decision within 30 days of the conclusion of the
hearing. If you are not satisfied with our decision, you have the right to take your complaint to the Office of
the Commissioner of Insurance.


Section 5.3 Exceptions for Emergency Situations
Your complaint requires immediate actions when your Dentist judges that a delay in treatment would
significantly increase the risk to your health. In these urgent situations:

•     The appeal does not need to be submitted in writing. You or your Dentist should call us as soon as
      possible.




DCOC.CPL.06                                       18
•     We will notify you of the decision by the end of the next business day after your complaint is
      received, unless more information is needed.

•     If we need more information from your Dentist to make a decision, we will notify you of the decision
      by the end of the next business day following receipt of the required information.
The complaint process for urgent situations does not apply to prescheduled treatments or procedures that
we do not consider urgent situations.
If you are not satisfied with our decision, you have the right to take your complaint to the Office of the
Commissioner of Insurance.




DCOC.CPL.06                                       19
                         Section 6: General Provisions
Section 6.1 Entire Policy
The Policy issued to the Enrolling Group, including the Certificate(s), Schedule(s) of Covered Dental
Services, the Enrolling Group's application, Amendments and Riders, constitute the entire Policy. All
statements made by the Enrolling Group or by a Subscriber will, in the absence of fraud, be deemed
representations and not warranties.


Section 6.2 Limitation of Action
You do not have the right to bring any legal proceeding or action against the Company without first
completing the complaint procedure specified in Section 5: Complaint Procedures. If you do not bring
such legal proceeding or action against the Company within 5 years of the date the Company notified you
of its final decision as described in Section 5: Complaint Procedures; you forfeit your rights to bring any
action against the Company.
The only exception to this limitation of action is that reimbursement of Eligible Expenses, as set forth in
Section 4: Reimbursement, is subject to the limitation of action provision of that Section.


Section 6.3 Time Limit on Certain Defenses
No statement, except a fraudulent statement, made by the Enrolling Group will be used to void the Policy
after it has been in force for a period of 2 years.


Section 6.4 Amendments and Alterations
Amendments to the Policy are effective upon 31 days written notice to the Enrolling Group. Riders are
effective on the date specified by the Company. No change will be made to the Policy unless it is made
by an Amendment or a Rider that is signed by an officer of the Company. No agent has authority to
change the Policy or to waive any of its provisions.


Section 6.5 Relationship Between Parties
The relationships between the Company and Network providers and relationships between the Company
and Enrolling Groups, are solely contractual relationships between independent contractors. Network
providers and Enrolling Groups are not agents or employees of the Company, nor is the Company or any
employee of the Company an agent or employee of Network providers or Enrolling Groups.
The relationship between a Network provider and any Covered Person is that of provider and patient. The
Network provider is solely responsible for the services provided to any Covered Person.
The relationship between the Enrolling Group and Covered Persons is that of employer and employee,
Dependent or other Coverage classification as defined in the Policy. The Enrolling Group is solely
responsible for enrollment and Coverage classification changes (including termination of a Covered
Person's Coverage through the Company), for the timely payment of the Policy Charge to the Company,
and for notifying Covered Persons of the termination of the Policy.


Section 6.6 Information and Records
At times the Company may need additional information from you. You agree to furnish the Company with
all information and proofs that the Company may reasonably require regarding any matters pertaining to



DCOC.GPR.06.FL                                   20
the Policy. If you do not provide this information when the Company requests it we may delay or deny
payment of your Benefits.
By accepting Benefits under the Policy, you authorize and direct any person or institution that has
provided services to you to furnish the Company with all information or copies of records relating to the
services provided to you. The Company has the right to request this information at any reasonable time.
This applies to all Covered Persons, including Enrolled Dependents whether or not they have signed the
Subscriber's enrollment form. The Company agrees that such information and records will be considered
confidential.
The Company has the right to release any and all records concerning dental care services which are
necessary to implement and administer the terms of the Policy, for appropriate review or quality
assessment, or as the Company is required to do by law or regulation. During and after the term of the
Policy, the Company and its related entities may use and transfer the information gathered under the
Policy in a de-identified format for commercial purposes, including research and analytic purposes.
For complete listings of your dental records or billing statements the Company recommends that you
contact your Dentist. Dentists may charge you reasonable fees to cover their costs for providing records
or completing requested forms.
If you request dental forms or records from us, the Company also may charge you reasonable fees to
cover costs for completing the forms or providing the records.
In some cases, the Company will designate other persons or entities to request records or information
from or related to you, and to release those records as necessary. The Company's designees have the
same rights to this information as the Company has.


Section 6.7 ERISA
When the Policy is purchased by the Enrolling Group to provide benefits under a welfare plan governed
by the Employee Retirement Income Security Act 29 U.S.C. §1001 et seq., the Company is not the plan
administrator or named fiduciary of the welfare plan, as those terms are used in ERISA.


Section 6.8 Examination of Covered Persons
In the event of a question or dispute concerning Coverage for Dental Services, the Company may
reasonably require that a Network Dentist acceptable to the Company examine you at the Company's
expense.


Section 6.9 Clerical Error
If a clerical error or other mistake occurs, that error will not deprive you of Coverage under the Policy. A
clerical error also does not create a right to benefits.


Section 6.10 Notice
When the Company provides written notice regarding administration of the Policy to an authorized
representative of the Enrolling Group, that notice is deemed notice to all affected Subscribers and their
Enrolled Dependents. The Enrolling Group is responsible for giving notice to Covered Persons.


Section 6.11 Workers' Compensation Not Affected
The Coverage provided under the Policy does not substitute for and does not affect any requirements for
coverage by workers' compensation insurance.




DCOC.GPR.06.FL                                   21
Section 6.12 Conformity with Statutes
Any provision of the Policy which, on its effective date, is in conflict with the requirements of state or
federal statutes or regulations (of the jurisdiction in which delivered) is hereby amended to conform to the
minimum requirements of such statutes and regulations.


Section 6.13 Waiver/Estoppel
Nothing in the Policy, Certificate or Schedule of Covered Dental Services is considered to be waived by
any party unless the party claiming the waiver receives the waiver in writing. A waiver of one provision
does not constitute a waiver of any other. A failure of either party to enforce at any time any of the
provisions of the Policy, Certificate or Schedule of Covered Dental Services, or to exercise any option
which is herein provided, shall in no way be construed to be a waiver of such provision of the Policy,
Certificate or Schedule of Covered Dental Services.


Section 6.14 Headings
The headings, titles and any table of contents contained in the Policy, Certificate or Schedule of Covered
Dental Services are for reference purposes only and shall not in any way affect the meaning or
interpretation of the Policy, Certificate or Schedule of Covered Dental Services.


Section 6.15 Unenforceable Provisions
If any provision of the Policy, Certificate or Schedule of Covered Dental Services is held to be illegal or
unenforceable by a court of competent jurisdiction, the remaining provisions will remain in effect and the
illegal or unenforceable provision will be modified so as to conform to the original intent of the Policy,
Certificate or Schedule of Covered Dental Services to the greatest extent legally permissible.




DCOC.GPR.06.FL                                   22
                   Section 7: Coordination of Benefits
Section 7.1 Coordination of Benefits Applicability
This coordination of benefits (COB) provision applies when a person has health or dental coverage under
more than one Coverage Plan. "Coverage Plan" is defined below.
The order of benefit determination rules below determine which Coverage Plan will pay as the primary
Coverage Plan. The primary Coverage Plan that pays first pays without regard to the possibility that
another Coverage Plan may cover some expenses. A secondary Coverage Plan pays after the primary
Coverage Plan and may reduce the benefits it pays so that payments from all group Coverage Plans do
not exceed 100% of the total allowable expense.


Section 7.2 Definitions
For purposes of this Section, Coordination of Benefits, terms are defined as follows:
A.    A "Coverage Plan" is any of the following that provides benefits or services for medical or dental
      care or treatment. However, if separate contracts are used to provide coordinated coverage for
      members of a group, the separate contracts are considered parts of the same Coverage Plan and
      there is no COB among those separate contracts.
      1.     "Plan" includes: group insurance, closed panel or other forms of group or group-type
             coverage (whether insured or uninsured); medical benefits under group or individual
             automobile contracts; and Medicare or other governmental benefits, as permitted by law.
      2.     "Plan" does not include: individual or family insurance; closed panel or other individual
             coverage (except for group-type coverage); school accident type coverage; benefits for non-
             medical components of group long-term care policies; Medicare supplement policies,
             Medicaid policies and coverage under other governmental plans, unless permitted by law.
      Each contract for coverage under (1.) or (2.) is a separate Coverage Plan. If a Coverage Plan has
      two parts and COB rules apply only to one of the two, each of the parts is treated as a separate
      Coverage Plan.
B.    The order of benefit determination rules determine whether this Coverage Plan is a "primary
      Coverage Plan" or "secondary Coverage Plan" when compared to another Coverage Plan covering
      the person.
      When this Coverage Plan is primary, its benefits are determined before those of any other
      Coverage Plan and without considering any other Coverage Plan's benefits. When this Coverage
      Plan is secondary, its benefits are determined after those of another Coverage Plan and may be
      reduced because of the primary Coverage Plan's benefits.
C.    "Allowable expense" means a health care service or expense, including deductibles and
      copayments, that is covered at least in part by any of the Coverage Plans covering the person.
      When a Coverage Plan provides benefits in the form of services, (for example a dental HMO) the
      reasonable cash value of each service will be considered an allowable expense and a benefit paid.
      An expense or service that is not covered by any of the Coverage Plans is not an allowable
      expense. The following are examples of expenses or services that are not allowable expenses:
      1.     If a person is covered by 2 or more Coverage Plans that compute their benefit payments on
             the basis of Usual and Customary fees, any amount in excess of the highest of the Usual
             and Customary fees for a specific benefit is not an allowable expense.




DCOC.COB.06                                     23
      2.    If a person is covered by 2 or more Coverage Plans that provide benefits or services on the
            basis of negotiated fees, an amount in excess of the highest of the negotiated fees is not an
            allowable expense.
      3.    If a person is covered by one Coverage Plan that calculates its benefits or services on the
            basis of Usual and Customary fees and another Coverage Plan that provides its benefits or
            services on the basis of negotiated fees, the primary Coverage Plan's payment
            arrangements will be the allowable expense for all Coverage Plans.
D.    "Claim determination period" means a calendar year. However, it does not include any part of a
      year during which a person has no coverage under this Coverage Plan, or before the date this
      COB provision or a similar provision takes effect.
E.    "Closed panel Coverage Plan" is a Coverage Plan that provides health or dental benefits to
      covered persons primarily in the form of services through a panel of providers that have contracted
      with or are employed by the Coverage Plan, and that limits or excludes benefits for services
      provided by other providers, except in cases of emergency or referral by a panel member.
F.    "Custodial parent" means a parent awarded custody by a court decree. In the absence of a court
      decree, it is the parent with whom the child resides more than one half of the calendar year without
      regard to any temporary visitation.


Section 7.3 Order of Benefit Determination Rules
When two or more Coverage Plans pay benefits, the rules for determining the order of payment are as
follows:
A.    The primary Coverage Plan pays or provides its benefits as if the secondary Coverage Plan or
      Coverage Plans did not exist.
B.    A Coverage Plan that does not contain a coordination of benefits provision that is consistent with
      this provision is always primary. There is one exception: coverage that is obtained by virtue of
      membership in a group that is designed to supplement a part of a basic package of benefits may
      provide that the supplementary coverage will be excess to any other parts of the Coverage Plan
      provided by the contract holder. Examples of these types of situations are major medical coverages
      that are superimposed over base Coverage Plan hospital and surgical benefits, and insurance type
      coverages that are written in connection with a closed panel Coverage Plan to provide out-of-
      network benefits.
C.    A Coverage Plan may consider the benefits paid or provided by another Coverage Plan in
      determining its benefits only when it is secondary to that other Coverage Plan.
D.    The first of the following rules that describes which Coverage Plan pays its benefits before another
      Coverage Plan is the rule to use.
      1.    Non-Dependent or Dependent. The Coverage Plan that covers the person other than as a
            dependent, for example as an employee, member, Subscriber or retiree is primary and the
            Coverage Plan that covers the person as a dependent is secondary. However, if the person
            is a Medicare beneficiary and, as a result of federal law, Medicare is secondary to the
            Coverage Plan covering the person as a dependent; and primary to the Coverage Plan
            covering the person as other than a dependent (e.g. a retired employee); then the order of
            benefits between the two Coverage Plans is reversed so that the Coverage Plan covering
            the person as an employee, member, Subscriber or retiree is secondary and the other
            Coverage Plan is primary.
      2.    Child Covered Under More Than One Plan. The order of benefits when a child is covered by
            more than one Coverage Plan is:




DCOC.COB.06                                    24
           a.     The primary Coverage Plan is the Coverage Plan of the parent whose birthday is
                  earlier in the year if:
                  1.)   The parents are married;
                  2.)   The parents are not separated (whether or not they ever have been married); or
                  3.)   A court decree awards joint custody without specifying that one party has the
                        responsibility to provide health care coverage.
           If both parents have the same birthday, the Coverage Plan that covered either of the parents
           longer is primary.
           b.     If the specific terms of a court decree state that one of the parents is responsible for
                  the child's health or dental care expenses or health or dental care coverage and the
                  Coverage Plan of that parent has actual knowledge of those terms, that Coverage
                  Plan is primary. This rule applies to claim determination periods or Coverage Plan
                  years commencing after the Coverage Plan is given notice of the court decree.
           c.     If the parents are not married, or are separated (whether or not they ever have been
                  married) or are divorced, the order of benefits is:
                  1.)   The Coverage Plan of the custodial parent;
                  2.)   The Coverage Plan of the spouse of the custodial parent;
                  3.)   The Coverage Plan of the noncustodial parent; and then
                  4.)   The Coverage Plan of the spouse of the noncustodial parent.
     3.    Active or inactive employee. The Coverage Plan that covers a person as an employee who
           is neither laid off nor retired is primary. The same would hold true if a person is a dependent
           of a person covered as a retiree and an employee. If the other Coverage Plan does not have
           this rule, and if, as a result, the Coverage Plans do not agree on the order of benefits, this
           rule is ignored. Coverage provided an individual as a retired worker and as a dependent of
           an actively working spouse will be determined under the rule labeled D.(1.).
     4.    Continuation coverage. If a person whose coverage is provided under a right of continuation
           provided by federal or state law also is covered under another Coverage Plan, the Coverage
           Plan covering the person as an employee, member, Subscriber or retiree (or as that
           person's dependent) is primary, and the continuation coverage is secondary. If the other
           Coverage Plan does not have this rule, and if, as a result, the Coverage Plans do not agree
           on the order of benefits, this rule is ignored.
     5.    Longer or shorter length of coverage. The Coverage Plan that covered the person as an
           employee, member, Subscriber or retiree longer is primary.
     6.    If the preceding rules do not determine the primary Coverage Plan, the allowable expenses
           will be shared equally between the Coverage Plans meeting the definition of Coverage Plan
           under this provision. In addition, this Coverage Plan will not pay more than it would have
           paid had it been primary.


Section 7.4 Effect on the Benefits of This Coverage Plan
A.   When this Coverage Plan is secondary, it may reduce its benefits so that the total benefits paid or
     provided by all Coverage Plans during a claim determination period are not more than 100 percent
     of total allowable expenses.
     When this Coverage Plan is the secondary carrier, this Coverage Plan will pay up to the claimed
     amount but never more than what this Coverage Plan would have paid as primary. The difference


DCOC.COB.06                                    25
      between what this Coverage Plan would have paid as primary and what is paid after coordination
      goes into a savings bank. This money will apply to any amounts between what is paid by both
      carriers but never greater than the claimed amount. Savings can be used on a current claim or
      banked for any other claim adjudicated during the calendar year.
B.    If a covered person is enrolled in two or more closed panel Coverage Plans and if, for any reason,
      including the provision of service by a non-panel provider, benefits are not payable by one closed
      panel Coverage Plan, COB will not apply between that Coverage Plan and other closed panel
      Coverage Plans.
C.    This Coverage Plan reduces its benefits as described below for Covered Persons who are eligible
      for Medicare when Medicare would be the primary Coverage Plan.
      Medicare benefits are determined as if the full amount that would have been payable under
      Medicare was actually paid under Medicare, even if:
           The person is not enrolled for Medicare. Medicare benefits are determined as if the person
            were covered under Medicare Parts A and B.
           The person is enrolled in a Medicare Advantage (Medicare Part C) plan and receives non-
            covered services because the person did not follow all rules of that plan. Medicare benefits
            are determined as if the services were covered under Medicare Parts A and B.
           The person receives services from a provider who has elected to opt-out of Medicare.
            Medicare benefits are determined as if the services were covered under Medicare Parts A
            and B and the provider had agreed to limit charges to the amount of charges allowed under
            Medicare rules.
           The services are provided in a Veterans Administration facility or other facility of the federal
            government. Medicare benefits are determined as if the services were provided by a non-
            governmental facility and covered under Medicare.
           The person is enrolled under a plan with a Medicare Medical Savings Account. Medicare
            benefits are determined as if the person were covered under Medicare Parts A and B.
           The person is enrolled in a Medicare Prescription Drug (Medicare Part D) plan and receives
            non-covered prescription drugs because the person did not follow all rules of that plan. If the
            drug is a Part D drug covered by the Medicare Prescription Drug plan, Medicare benefits are
            determined as if the services were provided by a network pharmacy and covered under
            Medicare Part D.


Section 7.5 Right to Receive and Release Needed Information
Certain facts about health or dental care coverage and services are needed to apply these COB rules and
to determine benefits payable under this Coverage Plan and other Coverage Plans. The Company may
get the facts it needs from or give them to other organizations or persons for the purpose of applying
these rules and determining benefits payable under this Coverage Plan and other Coverage Plans
covering the person claiming benefits. The Company need not tell, or get the consent of, any person to do
this. Each person claiming benefits under this Coverage Plan must give the Company any facts it needs
to apply those rules and determine benefit payable. If you do not provide the Company the information it
needs to apply these rules and determine the benefits payable, your claim for benefits will be denied.


Section 7.6 Payments Made
A payment made under another Coverage Plan may include an amount that should have been paid under
this Coverage Plan. If it does, the Company may pay that amount to the organization that made the
payment. That amount will then be treated as though it was a benefit paid under this Coverage Plan. The
Company will not have to pay that amount again. The term "payment made" includes providing benefits in


DCOC.COB.06                                     26
the form of services, in which case "payment made" means reasonable cash value of the benefits
provided in the form of services.


Section 7.7 Right of Recovery
If the amount of the payments made by the Company is more than it should have paid under this COB
provision, it may recover the excess from one or more of the persons it had paid or for whom it has paid;
or any other person or organization that may be responsible for the benefits or services provided for the
covered person. The "amount of the payments made" includes the reasonable cash value of any benefits
provided in the form of services.




DCOC.COB.06                                    27
      Section 8: Subrogation and Refund of Expenses
Subrogation is the substitution of one person or entity in the place of another with reference to a lawful
claim, demand or right. The Company will be subrogated to and will succeed to all rights of recovery,
under any legal theory of any type, for the reasonable value of services and benefits provided by the
Company to you from: (i.) third parties, including any person alleged to have caused you to suffer injuries
or damages; (ii.) your employer; or (iii.) any person or entity obligated to provide benefits or payments to
you, including benefits or payments for underinsured or uninsured motorist protection (these third parties
and persons or entities are collectively referred to as "Third Parties"). You agree to assign to the
Company all rights of recovery against Third Parties, to the extent of the reasonable value of services and
benefits provided by the Company, plus reasonable costs of collection.
You will cooperate with the Company in protecting the Company's legal rights to subrogation and
reimbursement, and acknowledge that the Company's rights will be considered as the first priority claim
against Third Parties, to be paid before any other claims by you are paid. You will do nothing to prejudice
the Company's rights under this provision, either before or after the need for services or benefits under
the Policy. The Company may, at its option, take necessary and appropriate action to preserve its rights
under these subrogation provisions, including filing suit in your name. For the reasonable value of
services provided under the Policy, the Company may collect, at its option, amounts from the proceeds of
any settlement (whether before or after any determination of liability) or judgment that may be recovered
by you or your legal representative, regardless of whether or not you have been fully compensated. You
will hold in trust any proceeds of settlement or judgment for the benefit of the Company under these
subrogation provisions and the Company will be entitled to recover reasonable attorney fees from you
incurred in collecting proceeds held by you. You will not accept any settlement that does not fully
compensate or reimburse the Company without the written approval of the Company. You agree to
execute and deliver such documents (including a written confirmation of assignment, and consents to
release dental records), and provide such help (including responding to requests for information about
any accident or injuries and making court appearances) as may be reasonably requested by the
Company.
Refund of Overpayments. If the Company pays benefits for expenses incurred on account of a Covered
Person, that Covered Person or any other person or organization that was paid must make a refund to
the Company if:
A.    All or some of the expenses were not paid by the Covered Person or did not legally have to be paid
      by the Covered Person,
B.    All or some of the payment made by the Company exceeded the benefits under the Policy, or
C.    All or some of the payment was made in error.
The refund equals the amount the Company paid in excess of the amount it should have paid under the
Policy.
If the refund is due from another person or organization, the Covered Person agrees to help the Company
get the refund when requested.
If the Covered Person, or any other person or organization that was paid, does not promptly refund the
full amount, the Company may reduce the amount of any future benefits that are payable under the
Policy. The Company may also reduce future benefits under any other group benefits plan administered
by the Company for the Enrolling Group. The reductions will equal the amount of the required refund. The
Company may have other rights in addition to the right to reduce future benefits.
Reimbursement of Benefits Paid. If the Company pays benefits for expenses incurred on account of a
Covered Person, the Subscriber or any other person or organization that was paid must make a refund to
the Company if all or some of the expenses were recovered from or paid by a source other than the




DCOC.SUB.06                                     28
Policy as a result of claims against a third party for negligence, wrongful acts or omissions. The refund
equals the amount of the recovery or payment, up to the amount the Company paid.
If the refund is due from another person or organization, the Covered Person agrees to help the Company
get the refund when requested.
If the Covered Person, or any other person or organization that was paid, does not promptly refund the
full amount, the Company may reduce the amount of any future benefits that are payable under the
Policy. The Company may also reduce future benefits under any other group benefits plan administered
by the Company for the Enrolling Group. The reduction will equal the amount of the required refund. The
Company may have other rights in addition to the right to reduce future benefits.




DCOC.SUB.06                                     29
                  Section 9: Continuation of Coverage
Section 9.1 Continuation Coverage
A Covered Person whose Coverage would otherwise end under the Policy may be entitled to elect
continuation Coverage in accordance with federal law (under COBRA) and as outlined in Sections 9.2
through 9.5 below.
Continuation Coverage under COBRA will be available only to Enrolling Groups which are subject to the
provisions of COBRA. Covered Persons should contact the Enrolling Group's plan administrator to
determine if he or she is entitled to continue Coverage under COBRA.
Continuation Coverage for Covered Persons who selected continuation coverage under a prior plan
which was replaced by Coverage under the Policy will terminate as scheduled under the prior plan or in
accordance with the terminating events set forth in Section 9.5 below, whichever is earlier.
In no event will the Company be obligated to provide continuation Coverage to a Covered Person if the
Enrolling Group or its designated plan administrator fails to perform its responsibilities under federal law.
These responsibilities include but are not limited to notifying the Covered Person in a timely manner of
the right to elect continuation Coverage and notifying the Company in a timely manner of the Covered
Person's election of continuation Coverage.
The Company is not the Enrolling Group's designated Plan Administrator and does not assume any
responsibilities of a Plan Administrator pursuant to federal law.
A Covered Person whose Coverage would otherwise end under the Policy may be entitled to elect
continuation Coverage in accordance with federal law, as outlined in Sections 9.2 through 9.5 below.


Section 9.2 Continuation Coverage Under Federal Law
In order to be eligible for continuation coverage under federal law, the Covered Person must meet the
definition of a "Qualified Beneficiary". A Qualified Beneficiary is any of the following persons who were
covered under the plan on the day before a Qualifying Event:

•     A Subscriber.

•     A Subscriber's Enrolled Dependent, including with respect to the Subscriber's children, a child born
      to or placed in adoption with a Subscriber during a period of continuation of coverage, or

•     A Subscriber's former spouse.


Section 9.3 Qualifying Events for Continuation Coverage Under
Federal Law
If a Qualified Beneficiary's Coverage will ordinarily terminate due to one of the following Qualifying
Events, he or she is entitled to continue Coverage. The Qualified Beneficiary is entitled to elect to
continue the same Coverage that he or she had at the time of the Qualifying Event.
A.    Termination of the Subscriber from employment with the Enrolling Group (for any reason other than
      gross misconduct) or reduction of hours; or
B.    Death of the Subscriber; or
C.    Divorce or legal separation of the Subscriber; or
D.    Loss of eligibility by an Enrolled Dependent who is a child; or


DCOC.CNT.06                                      30
E.    Entitlement of the Subscriber to Medicare benefits; or
F.    The Enrolling Group filing for bankruptcy, under Title XI, United States Code, on or after July 1,
      1986, but only for a retired Subscriber and his or her Enrolled Dependents. This is also a qualifying
      event for any retired Subscriber and his or her Enrolled Dependents if there is a substantial
      elimination of coverage within one year before or after the date the bankruptcy was filed.


Section 9.4 Notification Requirements and Election Period for
Continuation Coverage Under Federal Law
The Subscriber or Qualified Beneficiary must notify the Enrolling Group's designated plan administrator
within 60 days of his or her divorce, legal separation or an Enrolled Dependent's loss of eligibility as an
Enrolled Dependent. If the Subscriber or Qualified Beneficiary fails to notify the designated plan
administrator of these events within the 60 day period the Enrolling Group and its plan administrator are
not obligated to provide continuation Coverage to the affected Qualified Beneficiary. A Subscriber who is
continuing Coverage under Federal Law must notify the Enrolling Group's designated plan administrator
within 60 days of the birth or adoption of a child.
Continuation must be elected by the later of 60 days after the Qualifying Event occurs; or 60 days after
the Qualified Beneficiary receives notice of the continuation right from the Enrolling Group's designated
plan administrator.
A Qualified Beneficiary whose Coverage was terminated due to a qualifying event must pay the initial
Premium due to the Enrolling Group's designated plan administrator on or before the 45th day after
electing continuation.


Section 9.5 Terminating Events for Continuation Coverage Under
Federal Law
Continuation under the Policy will end on the earliest of the following dates:
A.    Eighteen months from the date of a Qualifying Event for a Qualified Beneficiary whose Coverage
      would have otherwise ended due to termination of employment (for reasons other than gross
      misconduct) or a reduction in hours. A Qualified Beneficiary who is determined to be disabled at
      the time during the first 60 days of continuation Coverage may extend continuation Coverage to a
      maximum of 29 months from the date of the Qualifying Event described in Section 9.3. If the
      Qualified Beneficiary entitled to the additional 11 months of Coverage has non-disabled family
      members who are also entitled to continuation Coverage, those non-disabled family members are
      also entitled to the additional 11 months of continuation Coverage.
      A Qualified Beneficiary who is determined to have been disabled within the first 60 days of
      continuation Coverage for Qualifying Event (A.) must provide notice of such disability within 60
      days after the determination of the disability, and in no event later than the end of the first 18
      months, in order to extend Coverage beyond 18 months. If such notice is provided, the Qualified
      Beneficiary's Coverage may be extended up to a maximum of 29 months from the date of the
      Qualifying Event described in Section 9.3. A or until the first month that begins more than 30 days
      after the date of any final determination that the Qualified Beneficiary is no longer disabled. Each
      Qualified Beneficiary must provide notice of any final determination that the Qualified Beneficiary is
      no longer disabled within 30 days of such determination.
B.    Thirty-six months from the date of the Qualifying Event for an Enrolled Dependent whose Coverage
      ended because of the death of the Subscriber, divorce or legal separation of the Subscriber, loss of
      eligibility by an Enrolled Dependent who is a child, in accordance with qualifying events (B.), (C.),
      or (D.) described in Section 9.3.




DCOC.CNT.06                                      31
C.    For the Enrolled Dependents of a Subscriber who was entitled to Medicare prior to a Qualifying
      Event that was due to either the termination of employment or work hours being reduced, eighteen
      months from the date of the Qualifying Event, or if later, 36 months from the date of the
      Subscriber's Medicare entitlement.
D.    The date Coverage terminates under the Policy for failure to make timely payment of the Premium.
E.    The date, after electing continuation Coverage, that coverage is obtained under any other group
      health plan. If such coverage contains a limitation or exclusion with respect to any preexisting
      condition of the Qualified Beneficiary, continuation will end on the date such limitation or exclusion
      ends. The other group health coverage will be primary for all health services except those health
      services that are subject to the preexisting condition limitation or exclusion.
F.    The date, after electing continuation Coverage, that the Qualified Beneficiary first becomes entitled
      to Medicare, except that this will not apply in the event the Qualified Beneficiary's Coverage was
      terminated because the Enrolling Group filed for bankruptcy, in accordance with qualifying event
      (F.) described in Section 9.3.
G.    The date the entire Policy ends.
H.    The date Coverage would otherwise terminate under the Policy.
If a Qualified Beneficiary is entitled to 18 months of continuation and a second Qualifying Event occurs
during that time, the continuation Coverage of a Qualified Beneficiary who is an Enrolled Dependent may
be extended up to a maximum of 36 months from the Qualifying Event described in Section 9.3 A. If a
Qualified Beneficiary is entitled to continuation because the Enrolling Group filed for bankruptcy, in
accordance with Qualifying Event (F.) described in Section 9.3 and the retired Subscriber dies during the
continuation period, the Enrolled Dependents will be entitled to continue Coverage for 36 months from the
date of death. Terminating events (B.) through (G.) described in this Section 9.5 will apply during the
extended continuation period.
Continuation Coverage for Qualified Beneficiaries whose continuation Coverage terminates because the
Subscriber becomes entitled to Medicare may be extended for an additional period of time. Such
Qualified Beneficiaries should contact the Enrolling Group's designated plan administrator for information
regarding the continuation period.




DCOC.CNT.06                                     32
        Section 10: Procedures for Obtaining Benefits
Section 10.1 Dental Services
You are eligible for Coverage for Dental Services listed in the Schedule of Covered Dental Services and
Section 11: Covered Dental Services of this Certificate if such Dental Services are Necessary and are
provided by or under the direction of a Dentist or other provider. All Coverage is subject to the terms,
conditions, exclusions and limitations of the Policy.
Network Benefits
Dental Services must be provided by a Network Dentist in order to be considered Network Benefits.
When Dental Services are received from a Non-Network Provider as a result of an Emergency, the
Copayment or Plan Allowance will be the Network Copayment or Plan Allowance.
Enrolling for Coverage under the Policy does not guarantee Dental Services by a particular Network
Dentist on the list of providers. The list of Network Dentists is subject to change. When a provider on the
list no longer has a contract with the Company, you must choose among remaining Network Dentists.
You are responsible for verifying the participation status of the Dentist, or other provider prior to receiving
such Dental Services. You must show your ID card every time you request Dental Services.
If you fail to verify participation status or to show your ID card, and the failure results in non-compliance
with required Company procedures, Coverage of Network Benefits may be denied.
Coverage for Dental Services is subject to payment of the Premium required for Coverage under the
Policy, satisfaction of any Deductible, appropriate Waiting Period, payment of the Copayment specified
for any service and payment of the percentage of Eligible Expenses shown in the Schedule of Covered
Dental Services and Section 11: Covered Dental Services.
Non-Network Benefits
Non-Network Benefits apply when you obtain Dental Services from Non-Network Dentists.
Before you are eligible for Coverage of Dental Services obtained from Non-Network Dentists, you must
meet the requirements for payment of any Deductible and appropriate Waiting Period specified in the
Schedule of Covered Dental Services and Section 11: Covered Dental Services. Non-Network Dentists
may request that you pay all charges when services are rendered. You must file a claim with the
Company for reimbursement of Eligible Expenses.
The Company reimburses a Non-Network Dentist for a covered Dental Service up to an amount equal to
the Usual and Customary fee for the same covered Dental Service received from a similarly situated
Network Dentist.
Network Dentists
The Company has arranged with certain dental care providers to participate in a Network. These Network
Dentists have agreed to discount their charges for Covered services and supplies.
If Network Dentists are used, the amount of Covered expenses for which a Covered Person is
responsible will generally be less than the amount owed if Non-Network Dentists had been used. The
Copayment level (the percentage of Covered expenses for which a Covered Person is responsible)
remains the same whether or not Network Dentists are used. However, because the total charges for
Covered expenses may be less when Network Dentists are used, the portion that the Covered Person
owes will generally be less.
Covered Persons are issued an identification card (ID card) showing they are eligible for Network
discounts. A Covered Person must show this ID card every time Dental Services are given. This is how


DCOC.OBT.06                                       33
the provider knows that the patient is Covered under a Network plan. Otherwise, the person could be
billed for the provider's normal charge.
A Directory of Network Dentists will be made available. A Covered Person can also call customer service
to determine which providers participate in the Network. The telephone number for customer services is
on the ID card.
Network Dentists are responsible for submitting a request for payment directly to the Company, however,
a Covered Person is responsible for any Copayment at the time of service. If a Network Dentist bills a
Covered Person, customer services should be called. A Covered Person does not need to submit claims
for Network Dentist services or supplies.


Section 10.2 Pre-Treatment Estimate
If the charge for a Dental Service is expected to exceed $500 or if a dental exam reveals the need for
fixed bridgework, you may notify the Company of such treatment before treatment begins and receive a
Pre-Treatment Estimate. If you desire a Pre-Treatment Estimate, you or your Dentist should send a notice
to the Company, via claim form, within 20 days of the exam. If requested the Dentist must provide the
Company with dental x-rays, study models or other information necessary to evaluate the treatment plan
for purposes of benefit determination.
The Company will determine if the proposed treatment is Covered under the Policy and estimate the
amount of payment. The estimate of benefits payable will be sent to the Dentist and will be subject to all
terms, conditions and provisions of the Policy. Clinical situations that can be effectively treated by a less
costly, clinically acceptable alternative procedure will be assigned a benefit based on the less costly
procedure.
Pre-Treatment Estimate of benefits is not an agreement to pay for expenses. This procedure lets the
Covered Person know in advance approximately what portion of the expenses will be considered for
payment.




DCOC.OBT.06                                       34
                 Section 11: Covered Dental Services
Dental Services described in this Section and in the Schedule of Covered Dental Services are Covered
when such services are:
A.    Necessary;
B.    Provided by or under the direction of a Dentist;
C.    Clinical situations that can be effectively treated by a less costly, dental appropriate alternative
      procedure will be assigned a benefit based on the least costly procedure; and
D.    Not excluded as described in Section 12: General Exclusions.
Covered Dental Services are subject to the satisfaction of any applicable Waiting Periods, Deductibles,
Maximum Benefits, and payment of any Copayments as described below and in the Schedule of Covered
Dental Services.
This Section and the Schedule of Covered Dental Services: (1) describe the Covered Dental Services
and any applicable limitations to those services; (2) outline the Copayments that you are required to pay
and any applicable Waiting Periods for each Covered Dental Service; and (3) describe any Deductible
and any Maximum Benefits that may apply.
Network Benefits:
When Network Copayments are charged as a percentage of Eligible Expenses, the amount you pay for
Dental Services from Network providers is determined as a percentage of the negotiated contract fee
between the Company and the provider rather than a percentage of the provider's billed charge. The
Company's negotiated rate with the provider is ordinarily lower than the provider's billed charge.
A Network provider cannot charge a Covered Person or the Company for any service or supply that is not
Necessary as determined by the Company. If a Covered Person agrees to receive a service or supply
that is not Necessary the Network provider may charge the Covered Person. However, these charges will
not be considered Covered Dental Services and will not be payable by the Company.
Non-Network Benefits:
When Copayments are charged as a percentage of Usual and Customary fees, the amount you pay for
Dental Services from Non-Network providers is determined as a percentage of the Usual and Customary
fee plus the amount by which the Non-Network provider's billed charge exceeds the Usual and
Customary fee.
Deductible
Deductible is $50 per Covered Person for Network Benefits and $50 per Covered Person for Non-
Network Benefits per calendar year, not to exceed $150 for Network Benefits and $150 for Non-Network
Benefits for all Covered Persons in a family.
The Deductible does not apply to: DIAGNOSTIC SERVICES and/or PREVENTIVE SERVICES.
The Deductible for Network Benefits applies to any combination of the following Covered Dental Services:
MINOR RESTORATIVE SERVICES, ENDODONTICS, PERIODONTICS, ORAL SURGERY,
ADJUNCTIVE SERVICES, MAJOR RESTORATIVE SERVICES, FIXED PROSTHETICS, REMOVABLE
PROSTHETICS.
The Deductible for Non-Network Benefits applies to any combination of the following Covered Dental
Services: MINOR RESTORATIVE SERVICES, ENDODONTICS, PERIODONTICS, ORAL SURGERY,
ADJUNCTIVE SERVICES, MAJOR RESTORATIVE SERVICES, FIXED PROSTHETICS, REMOVABLE
PROSTHETICS.


DCOC.CDS.06                                      35
Maximum Benefit
Maximum Benefit is $1,000 per Covered Person for Network Benefits and Non-Network Benefits
combined per calendar year.
Maximum Benefit for Network Benefits applies to any combination of the following Covered Dental
Services: MINOR RESTORATIVE SERVICES, ENDODONTICS, PERIODONTICS, ORAL SURGERY,
ADJUNCTIVE SERVICES, MAJOR RESTORATIVE SERVICES, FIXED PROSTHETICS, REMOVABLE
PROSTHETICS, ORTHODONTICS.
Maximum Benefit for Non-Network Benefits applies to any combination of the following Covered Dental
Services: MINOR RESTORATIVE SERVICES, ENDODONTICS, PERIODONTICS, ORAL SURGERY,
ADJUNCTIVE SERVICES, MAJOR RESTORATIVE SERVICES, FIXED PROSTHETICS, REMOVABLE
PROSTHETICS, ORTHODONTICS.
Maximum Policy Benefit
There are separate Maximum Policy Benefits that apply to specific Covered Dental Services. The
Maximum Policy Benefit that applies to a specific Covered Dental Service is listed below.The Maximun
Policy Benefit applies per Covered Person.
The Maximum Policy Benefits that apply to specific Covered Dental Services for Network Benefits and
Non-Network Benefits combined are: ORTHODONTICS: $2,000
Any required Copayment, Deductible, Waiting Period or Maximum Benefit is waived for a Covered Person
in their 2nd or 3rd trimester of pregnancy for the following Covered Dental Services: prophylaxis, scaling
and root planing, periodontal maintenance, full mouth debridement.


Section 11.1 CREDIT FOR PRIOR COVERAGE
If you are a Covered Person that becomes Covered under this Policy due to a mid-year plan change
and/or had prior Orthodontic coverage under another policy, you will need to submit evidence of having
satisfied any portion of your prior policy's Deductible in order to receive credit under this Policy's
applicable Deductible(s). You will also need to submit evidence of the total benefits paid under your prior
policy in order to have the amount applied to this Policy's applicable Maximum(s).
Waiting Periods apply to all Covered Persons. Covered Dental Services are subject to the satisfaction of
the appropriate Waiting Periods, which will be waived for all Covered Persons who enroll on the Enrolling
Group's Effective Date. All other Covered Persons are subject to the Waiting Periods unless evidence is
provided to the Company of uninterrupted prior comparable coverage that satisfies the Waiting Period.




DCOC.CDS.06                                     36
                       Section 12: General Exclusions
Section 12.1 Exclusions
Except as may be specifically provided in the Schedule of Covered Dental Services or through a Rider to
the Policy, the following are not Covered:
A.    Dental Services that are not Necessary.
B.    Hospitalization or other facility charges.
C.    Any Dental Procedure performed solely for cosmetic/aesthetic reasons. (Cosmetic procedures are
      those procedures that improve physical appearance.)
D.    Reconstructive surgery, regardless of whether or not the surgery is incidental to a dental disease,
      injury, or Congenital Anomaly, when the primary purpose is to improve physiological functioning of
      the involved part of the body.
E.    Any Dental Procedure not directly associated with dental disease.
F.    Any Dental Procedure not performed in a dental setting.
G.    Procedures that are considered to be Experimental, Investigational or Unproven. This includes
      pharmacological regimens not accepted by the American Dental Association (ADA) Council on
      Dental Therapeutics. The fact that an Experimental, Investigational or Unproven Service,
      treatment, device or pharmacological regimen is the only available treatment for a particular
      condition will not result in Coverage if the procedure is considered to be Experimental,
      Investigational or Unproven in the treatment of that particular condition.
H.    Placement of dental implants, implant-supported abutments and prostheses.
I.    Drugs/medications, obtainable with or without a prescription, unless they are dispensed and utilized
      in the dental office during the patient visit.
J.    Services for injuries or conditions paid for by Worker's Compensation or employer liability laws, and
      services that are provided without cost to the Covered Person by any municipality, county, or other
      political subdivision. This exclusion does not apply to any services covered by Medicaid or
      Medicare.
K.    Setting of facial bony fractures and any treatment associated with the dislocation of facial skeletal
      hard tissue.
L.    Treatment of benign neoplasms, cysts, or other pathology involving benign lesions, except
      excisional removal. Treatment of malignant neoplasms or Congenital Anomalies of hard or soft
      tissue, including excision.
M.    Replacement of complete dentures, and fixed and removable partial dentures or crowns, if damage
      or breakage was directly related to provider error. This type of replacement is the responsibility of
      the Dentist. If replacement is Necessary because of patient non-compliance, the patient is liable for
      the cost of replacement.
N.    Services related to the temporomandibular joint (TMJ), either bilateral or unilateral. Upper and
      lower jaw bone surgery (including that related to the temporomandibular joint). No Coverage is
      provided for orthognathic surgery, jaw alignment, or treatment for the temporomandibular joint.
O.    Charges for failure to keep a scheduled appointment without giving the dental office 24 hours
      notice.




DCOC.EXC.06.FL                                     37
P.    Expenses for Dental Procedures begun prior to the Covered Person becoming enrolled under the
      Policy.
Q.    Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or
      reconstruction.
R.    Attachments to conventional removable prostheses or fixed bridgework. This includes semi-
      precision or precision attachments associated with partial dentures, crown or bridge abutments, full
      or partial overdentures, any internal attachment associated with an implant prosthesis, and any
      elective endodontic procedure related to a tooth or root involved in the construction of a prosthesis
      of this nature.
S.    Procedures related to the reconstruction of a patient's correct vertical dimension of occlusion
      (VDO).
T.    Replacement of crowns, bridges, and fixed or removable prosthetic appliances inserted prior to
      plan Coverage unless the patient has been Covered under the Policy for 12 continuous months. If
      loss of a tooth requires the addition of a clasp, pontic, and/or abutment(s) within this 12 month
      period, the plan is responsible only for the procedures associated with the addition.
U.    Replacement of missing natural teeth lost prior to the onset of plan Coverage until the patient has
      been Covered under the Policy for 12 continuous months.
V.    Occlusal guards used as safety items or to affect performance primarily in sports-related activities.
W.    Placement of fixed partial dentures solely for the purpose of achieving periodontal stability.
X.    Services rendered by a provider with the same legal residence as a Covered Person or who is a
      member of a Covered Person's family, including spouse, brother, sister, parent or child.
Y.    Dental Services otherwise Covered under the Policy, but rendered after the date individual
      Coverage under the Policy terminates, including Dental Services for dental conditions arising prior
      to the date individual Coverage under the Policy terminates.
Z.    Acupuncture; acupressure and other forms of alternative treatment, whether or not used as
      anesthesia.
AA.   Orthodontic coverage does not include the installation of a space maintainer, any treatment related
      to treatment of the temporomandibular joint, any surgical procedure to correct a malocclusion,
      replacement of lost or broken retainers and/or habit appliances, and any fixed or removable
      interceptive orthodontic appliances previously submitted for payment under the plan.
BB.   In the event that a Non-Network Dentist routinely waives Copayments and/or the Deductible for a
      particular Dental Service, the Dental Service for which the Copayments and/or Deductible are
      waived is reduced by the amount waived by the Non-Network provider.
CC.   Foreign Services are not Covered unless required as an Emergency.
DD.   Dental Services received as a result of war or any act of war, whether declared or undeclared or
      caused during service in the armed forces of any country.
EE.   Any Dental Services or Procedures not listed in the Schedule of Covered Dental Services.




DCOC.EXC.06.FL                                  38
        SCHEDULE OF COVERED DENTAL SERVICES
BENEFIT DESCRIPTION &               NETWORK                            NON-NETWORK
LIMITATION
                                    COPAYMENT                          COPAYMENT
                                    is shown as a percentage of        is shown as a percentage of
                                    Eligible Expenses or is shown as   Eligible Expenses or is shown as
                                    a fixed dollar after applicable    a fixed dollar after applicable
                                    Deductible is satisfied.           Deductible is satisfied.
                                                                       You must also pay the amount of
                                                                       the Dentist's fee, if any, which is
                                                                       greater than the Eligible
                                                                       Expense.

DIAGNOSTIC SERVICES

Bacteriologic Cultures              0%                                 10%

Viral Cultures                      0%                                 10%

Intraoral Bitewing Radiographs      0%                                 10%
Limited to 1 series of films per
calendar year.

Panorex Radiographs                 0%                                 10%
Limited to 1 time per consecutive
36 months.

Oral/Facial Photographic Images     0%                                 10%
Limited to 1 time per consecutive
36 months.

Diagnostic Casts                    0%                                 10%
Limited to 1 time per consecutive
24 months.

Extraoral Radiographs               0%                                 10%
Limited to 2 films per calendar
year.

Intraoral - Complete Series         0%                                 10%
(including bitewings)
Limited to 1 time per consecutive
36 months. Vertical bitewings
can not be billed in conjunction
with a complete series.

Intraoral Periapical Radiographs    0%                                 10%




DSCH.IPO.06                                    1
BENEFIT DESCRIPTION &                 NETWORK                            NON-NETWORK
LIMITATION
                                      COPAYMENT                          COPAYMENT
                                      is shown as a percentage of        is shown as a percentage of
                                      Eligible Expenses or is shown as   Eligible Expenses or is shown as
                                      a fixed dollar after applicable    a fixed dollar after applicable
                                      Deductible is satisfied.           Deductible is satisfied.
                                                                         You must also pay the amount of
                                                                         the Dentist's fee, if any, which is
                                                                         greater than the Eligible
                                                                         Expense.

Pulp Vitality Tests                   0%                                 10%
Limited to 1 charge per visit,
regardless of how many teeth
are tested.

Intraoral Occlusal Film               0%                                 10%

Periodic Oral Evaluation              0%                                 10%
Limited to 2 times per
consecutive 12 months.

Comprehensive Oral Evaluation         0%                                 10%
Limited to 2 times per
consecutive 12 months. Not
Covered if done in conjunction
with other exams.

Limited or Detailed Oral              0%                                 10%
Evaluation
Limited to 2 times per
consecutive 12 months. Only 1
exam is Covered per date of
service.

Comprehensive Periodontal             0%                                 10%
Evaluation - new or established
patient
Limited to 2 times per
consecutive 12 months.

Adjunctive Pre-Diagnostic Test        0%                                 10%
that aids in detection of mucosal
abnormalities including
premalignant and malignant
lesions, not to include cytology or
biopsy procedures
Limited to 1 time per consecutive
12 months.




DSCH.IPO.06                                      2
BENEFIT DESCRIPTION &                 NETWORK                            NON-NETWORK
LIMITATION
                                      COPAYMENT                          COPAYMENT
                                      is shown as a percentage of        is shown as a percentage of
                                      Eligible Expenses or is shown as   Eligible Expenses or is shown as
                                      a fixed dollar after applicable    a fixed dollar after applicable
                                      Deductible is satisfied.           Deductible is satisfied.
                                                                         You must also pay the amount of
                                                                         the Dentist's fee, if any, which is
                                                                         greater than the Eligible
                                                                         Expense.

PREVENTIVE SERVICES

Dental Prophylaxis                    0%                                 10%
Limited to 2 times per
consecutive 12 months.

Fluoride Treatments - child           0%                                 10%
Limited to Covered Persons
under the age of 16 years, and
limited to 2 times per consecutive
12 months.

Sealants                              0%                                 10%
Limited to Covered Persons
under the age of 16 years and
once per first or second
permanent molar every
consecutive 36 months.

Space Maintainers                     0%                                 10%
Limited to Covered Persons
under the age of 16 years, once
per consecutive 60 months .
Benefit includes all adjustments
within 6 months of installation.

Re-Cement Space Maintainers           0%                                 10%
Limited to 1 per consecutive 6
months after initial insertion.

MINOR RESTORATIVE SERVICES

Amalgam Restorations                  80%                                70%
Multiple restorations on one                                             Subject to a 12 month Waiting
surface will be treated as a single                                      Period.
filling.




DSCH.IPO.06                                      3
BENEFIT DESCRIPTION &                 NETWORK                            NON-NETWORK
LIMITATION
                                      COPAYMENT                          COPAYMENT
                                      is shown as a percentage of        is shown as a percentage of
                                      Eligible Expenses or is shown as   Eligible Expenses or is shown as
                                      a fixed dollar after applicable    a fixed dollar after applicable
                                      Deductible is satisfied.           Deductible is satisfied.
                                                                         You must also pay the amount of
                                                                         the Dentist's fee, if any, which is
                                                                         greater than the Eligible
                                                                         Expense.

Composite Resin Restorations -        80%                                70%
Anterior
                                                                         Subject to a 12 month Waiting
Multiple restorations on one                                             Period.
surface will be treated as a single
filling.

Gold Foil Restorations                80%                                70%
Multiple restorations on one                                             Subject to a 12 month Waiting
surface will be treated as a single                                      Period.
filling.

ENDODONTICS

Apexification                         80%                                70%
Limited to 1 time per tooth per
lifetime.

Apicoectomy and Retrograde            80%                                70%
Filling
Limited to 1 time per tooth per
lifetime.

Hemisection                           80%                                70%
Limited to 1 time per tooth per
lifetime.

Root Canal Therapy                    80%                                70%
Limited to 1 time per tooth per
lifetime. Dentist who performed
the original root canal should not
be reimbursed for the
retreatment for the first 12
months.




DSCH.IPO.06                                      4
BENEFIT DESCRIPTION &                NETWORK                            NON-NETWORK
LIMITATION
                                     COPAYMENT                          COPAYMENT
                                     is shown as a percentage of        is shown as a percentage of
                                     Eligible Expenses or is shown as   Eligible Expenses or is shown as
                                     a fixed dollar after applicable    a fixed dollar after applicable
                                     Deductible is satisfied.           Deductible is satisfied.
                                                                        You must also pay the amount of
                                                                        the Dentist's fee, if any, which is
                                                                        greater than the Eligible
                                                                        Expense.

Retreatment of Previous Root         80%                                70%
Canal Therapy
Dentist who performed the
original root canal should not be
reimbursed for the retreatment
for the first 12 months.

Root Resection/Amputation            80%                                70%
Limited to 1 time per tooth per
lifetime.

Therapeutic Pulpotomy                80%                                70%
Limited to 1 time per primary or
secondary tooth per lifetime.

Pulpal Therapy (resorbable           80%                                70%
filling) - Anterior or Posterior,
Primary Tooth (excluding final
restoration)
Limited to 1 time per tooth per
lifetime. Covered for anterior or
posterior teeth only.

Pulp Caps - Direct/Indirect –        80%                                70%
excluding final restoration
Not covered if utilized soley as a
liner or base underneath a
restoration.

Pulpal Debridement, Primary and      80%                                70%
Permanent Teeth
Limited to 1 time per tooth per
lifetime. This procedure is not to
be used when endodontic
services are done on same date
of service.




DSCH.IPO.06                                     5
BENEFIT DESCRIPTION &               NETWORK                            NON-NETWORK
LIMITATION
                                    COPAYMENT                          COPAYMENT
                                    is shown as a percentage of        is shown as a percentage of
                                    Eligible Expenses or is shown as   Eligible Expenses or is shown as
                                    a fixed dollar after applicable    a fixed dollar after applicable
                                    Deductible is satisfied.           Deductible is satisfied.
                                                                       You must also pay the amount of
                                                                       the Dentist's fee, if any, which is
                                                                       greater than the Eligible
                                                                       Expense.

PERIODONTICS

Crown Lengthening                   80%                                70%
Limited to 1 per quadrant or site
per consecutive 36 months.

Gingivectomy/Gingivoplasty          80%                                70%
Limited to 1 per quadrant or site
per consecutive 36 months.

Gingival Flap Procedure             80%                                70%
Limited to 1 per quadrant or site
per consecutive 36 months.

Osseous Graft                       80%                                70%
Limited to 1 per quadrant or site
per consecutive 36 months.

Osseous Surgery                     80%                                70%
Limited to 1 per quadrant or site
per consecutive 36 months.

Guided Tissue Regeneration          80%                                70%
Limited to 1 per quadrant or site
per consecutive 36 months.

Soft Tissue Surgery                 80%                                70%
Limited to 1 per quadrant or site
per consecutive 36 months.

Periodontal Maintenance             80%                                70%
Limited to 2 times per
consecutive 12 months following
active or adjunctive periodontal
therapy, exclusive of gross
debridement.




DSCH.IPO.06                                    6
BENEFIT DESCRIPTION &                 NETWORK                            NON-NETWORK
LIMITATION
                                      COPAYMENT                          COPAYMENT
                                      is shown as a percentage of        is shown as a percentage of
                                      Eligible Expenses or is shown as   Eligible Expenses or is shown as
                                      a fixed dollar after applicable    a fixed dollar after applicable
                                      Deductible is satisfied.           Deductible is satisfied.
                                                                         You must also pay the amount of
                                                                         the Dentist's fee, if any, which is
                                                                         greater than the Eligible
                                                                         Expense.

Full Mouth Debridement                80%                                70%
Limited to once per consecutive
36 months.

Provisional Splinting                 80%                                70%
Cannot be used to restore
vertical dimension or as part of
full mouth rehabilitation, should
not include use of laboratory
based crowns and/or fixed partial
dentures (bridges).
Exclusion of laboratory based
crowns or bridges for the
purposes of provisional splinting.

Scaling and Root Planing              80%                                70%
Limited to 1 time per quadrant
per consecutive 24 months.

Localized Delivery of                 80%                                70%
Antimicrobial Agents via a
controlled release vehicle into
diseased crevicular tissue, per
tooth, by report
Limited to 3 sites per quadrant,
or 12 sites total, for refractory
pockets, or in conjunction with
scaling or root planing, by report.

ORAL SURGERY

Alveoloplasty                         80%                                70%

Biopsy                                80%                                70%
Limited to 1 biopsy per site per
visit.

Frenectomy/Frenuloplasty              80%                                70%




DSCH.IPO.06                                      7
BENEFIT DESCRIPTION &              NETWORK                            NON-NETWORK
LIMITATION
                                   COPAYMENT                          COPAYMENT
                                   is shown as a percentage of        is shown as a percentage of
                                   Eligible Expenses or is shown as   Eligible Expenses or is shown as
                                   a fixed dollar after applicable    a fixed dollar after applicable
                                   Deductible is satisfied.           Deductible is satisfied.
                                                                      You must also pay the amount of
                                                                      the Dentist's fee, if any, which is
                                                                      greater than the Eligible
                                                                      Expense.

Surgical Incision                  80%                                70%
Limited to 1 per site per visit.

Removal of a Benign                80%                                70%
Cyst/Lesions
Limited to 1 per site per visit.

Removal of Torus                   80%                                70%
Limited to 1 per site per visit.

Root Removal, Surgical             80%                                70%
Limited to 1 time per tooth per
lifetime.

Simple Extractions                 80%                                70%
Limited to 1 time per tooth per
lifetime.

Surgical Extraction of Erupted     80%                                70%
Teeth or Roots
Limited to 1 time per tooth per
lifetime.

Surgical Extraction of Impacted    80%                                70%
Teeth
Limited to 1 time per tooth per
lifetime.

Surgical Access, Surgical          80%                                70%
Exposure, or Immobilization of
Unerupted Teeth
Limited to 1 time per tooth per
lifetime.

Primary Closure of a Sinus         80%                                70%
Perforation
Limited to 1 per tooth per
lifetime.



DSCH.IPO.06                                   8
BENEFIT DESCRIPTION &                 NETWORK                            NON-NETWORK
LIMITATION
                                      COPAYMENT                          COPAYMENT
                                      is shown as a percentage of        is shown as a percentage of
                                      Eligible Expenses or is shown as   Eligible Expenses or is shown as
                                      a fixed dollar after applicable    a fixed dollar after applicable
                                      Deductible is satisfied.           Deductible is satisfied.
                                                                         You must also pay the amount of
                                                                         the Dentist's fee, if any, which is
                                                                         greater than the Eligible
                                                                         Expense.

Placement of Device to Facilitate     80%                                70%
Eruption of Impacted Tooth
Limited to 1 time per tooth per
lifetime.

Transseptal Fiberotomy/Supra          80%                                70%
Crestal Fiberotomy, by report
Limited to 1 time per tooth per
lifetime.

Vestibuloplasty                       80%                                70%
Limited to 1 time per site per
consecutive 60 months.

Bone Replacement Graft for            80%                                70%
Ridge Preservation - per site
Limited to 1 per site per lifetime
Not Covered if done in
conjunction with other bone graft
replacement procedures.

Excision of Hyperplastic Tissue       80%                                70%
or Pericoronal Gingiva
Limited to 1 per site per
consecutive 36 months.

Appliance Removal (not by             80%                                70%
dentist who placed appliance)
includes removal of arch bar
Limited to once per appliance per
lifetime.

Tooth Reimplantation and/or           80%                                70%
Transplantation Services
Limited to 1 per site per lifetime.

Oroantral Fistula Closure             80%                                70%
Limited to 1 per site per visit.



DSCH.IPO.06                                      9
BENEFIT DESCRIPTION &                NETWORK                            NON-NETWORK
LIMITATION
                                     COPAYMENT                          COPAYMENT
                                     is shown as a percentage of        is shown as a percentage of
                                     Eligible Expenses or is shown as   Eligible Expenses or is shown as
                                     a fixed dollar after applicable    a fixed dollar after applicable
                                     Deductible is satisfied.           Deductible is satisfied.
                                                                        You must also pay the amount of
                                                                        the Dentist's fee, if any, which is
                                                                        greater than the Eligible
                                                                        Expense.

ADJUNCTIVE SERVICES

Analgesia                            80%                                70%
Covered when Necessary in
conjunction with Covered Dental
Services. If required for patients
under 6 years of age or patients
with behavioral problems or
physical disabilities or if it is
clinically Necessary. Covered for
patients over age of 6 if it is
clinically Necessary.

Desensitizing Medicament             80%                                70%

General Anesthesia                   80%                                70%
Covered when Necessary in
conjunction with Covered Dental
Services. If required for patients
under 6 years of age or patients
with behavioral problems or
physical disabilities or if it is
clinically Necessary. Covered for
patients over age of 6 if it is
clinically Necessary.

Local Anesthesia                     80%                                70%
Not Covered in conjunction with
operative or surgical procedure.

Intravenous Sedation and             80%                                70%
Analgesia
Covered when Necessary in
conjunction with Covered Dental
Services. If required for patients
under 6 years of age or patients
with behavioral problems or
physical disabilities or if it is




DSCH.IPO.06                                     10
BENEFIT DESCRIPTION &                  NETWORK                            NON-NETWORK
LIMITATION
                                       COPAYMENT                          COPAYMENT
                                       is shown as a percentage of        is shown as a percentage of
                                       Eligible Expenses or is shown as   Eligible Expenses or is shown as
                                       a fixed dollar after applicable    a fixed dollar after applicable
                                       Deductible is satisfied.           Deductible is satisfied.
                                                                          You must also pay the amount of
                                                                          the Dentist's fee, if any, which is
                                                                          greater than the Eligible
                                                                          Expense.
clinically Necessary. Covered for
patients over age of 6 if it is
clinically Necessary.

Therapeutic Drug Injection, by         80%                                70%
report/Other Drugs and/or
Medicaments, by report
Limited to 1 per visit.

Occlusal Adjustment                    80%                                70%

Occlusal Guards                        80%                                70%
Limited to 1 guard every
consecutive 36 months and only
covered if prescribed to control
habitual grinding.

Occlusal Guard Reline and              80%                                70%
Repair
Limited to relining and repair
performed more than 6 months
after the initial insertion. Limited
to 1 time per consecutive 12
months.

Occlusion Analysis - Mounted           80%                                70%
Case
Limited to 1 time per consecutive
60 months.

Palliative Treatment                   80%                                70%
Covered as a separate benefit
only if no other services, other
than exam and radiographs,
were done on the same tooth
during the visit.




DSCH.IPO.06                                       11
BENEFIT DESCRIPTION &                NETWORK                             NON-NETWORK
LIMITATION
                                     COPAYMENT                           COPAYMENT
                                     is shown as a percentage of         is shown as a percentage of
                                     Eligible Expenses or is shown as    Eligible Expenses or is shown as
                                     a fixed dollar after applicable     a fixed dollar after applicable
                                     Deductible is satisfied.            Deductible is satisfied.
                                                                         You must also pay the amount of
                                                                         the Dentist's fee, if any, which is
                                                                         greater than the Eligible
                                                                         Expense.

Consultation (diagnostic service     80%                                 70%
provided by dentists or physician
other than practitioner providing
treatment.)
Not Covered if done with exams
or professional visit.

MAJOR RESTORATIVE SERVICES
Replacement of complete dentures, fixed or removable partial dentures, crowns, inlays or onlays
previously submitted for payment under the plan is limited to 1 time per consecutive 60 months from initial
or supplemental placement.

Coping                               50%                                 60%
Limited to 1 per tooth per           Subject to a 12 month Waiting       Subject to a 12 month Waiting
consecutive 60 months. Not           Period.                             Period.
Covered if done at the same time
as a crown on same tooth.

Crowns – Retainers/Abutments         50%                                 60%
Limited to 1 time per tooth per      Subject to a 12 month Waiting       Subject to a 12 month Waiting
consecutive 60 months. Not           Period.                             Period.
Covered if done in conjunction
with any other inlay, onlay and
crown codes except post and
core buildup codes.

Crowns - Restorations                50%                                 60%
Limited to 1 time per tooth per      Subject to a 12 month Waiting       Subject to a 12 month Waiting
consecutive 60 months. Covered       Period.                             Period.
only when a filling cannot restore
the tooth. Not Covered if done in
conjunction with any other inlay,
onlay and crown codes except
post and core buildup codes.




DSCH.IPO.06                                     12
BENEFIT DESCRIPTION &                NETWORK                            NON-NETWORK
LIMITATION
                                     COPAYMENT                          COPAYMENT
                                     is shown as a percentage of        is shown as a percentage of
                                     Eligible Expenses or is shown as   Eligible Expenses or is shown as
                                     a fixed dollar after applicable    a fixed dollar after applicable
                                     Deductible is satisfied.           Deductible is satisfied.
                                                                        You must also pay the amount of
                                                                        the Dentist's fee, if any, which is
                                                                        greater than the Eligible
                                                                        Expense.

Temporary Crowns -                   50%                                60%
Restorations
                                     Subject to a 12 month Waiting      Subject to a 12 month Waiting
Limited to 1 time per tooth per      Period.                            Period.
consecutive 60 months. Covered
only when a filling cannot restore
the tooth. Not Covered if done in
conjunction with any other inlay,
onlay and crown codes except
post and core buildup codes.

Inlays/Onlays –                      50%                                60%
Retainers/Abutments
                                     Subject to a 12 month Waiting      Subject to a 12 month Waiting
Limited to 1 time per tooth per 60   Period.                            Period.
consecutive months. Not
Covered if done in conjunction
with any other inlay, onlay and
crown codes except post and
core buildup codes.

Inlays/Onlays - Restorations         50%                                60%
Limited to 1 time per tooth per      Subject to a 12 month Waiting      Subject to a 12 month Waiting
consecutive 60 months. Covered       Period.                            Period.
only when a filling cannot restore
the tooth. Not Covered if done in
conjunction with any other inlay,
onlay and crown codes except
post and core buildup codes.

Pontics                              50%                                60%
Limited to 1 time per tooth per      Subject to a 12 month Waiting      Subject to a 12 month Waiting
consecutive 60 months.               Period.                            Period.

Retainer-Cast Metal for Resin        50%                                60%
Bonded Fixed Prosthesis
                                     Subject to a 12 month Waiting      Subject to a 12 month Waiting
Limited to 1 time per tooth per      Period.                            Period.
consecutive 60 months.




DSCH.IPO.06                                     13
BENEFIT DESCRIPTION &                NETWORK                            NON-NETWORK
LIMITATION
                                     COPAYMENT                          COPAYMENT
                                     is shown as a percentage of        is shown as a percentage of
                                     Eligible Expenses or is shown as   Eligible Expenses or is shown as
                                     a fixed dollar after applicable    a fixed dollar after applicable
                                     Deductible is satisfied.           Deductible is satisfied.
                                                                        You must also pay the amount of
                                                                        the Dentist's fee, if any, which is
                                                                        greater than the Eligible
                                                                        Expense.

Pin Retention                        50%                                60%
Limited to 2 pins per tooth; not     Subject to a 12 month Waiting      Subject to a 12 month Waiting
covered in addition to cast          Period.                            Period.
restoration.

Post and Cores                       50%                                60%
Covered only for teeth that have     Subject to a 12 month Waiting      Subject to a 12 month Waiting
had root canal therapy.              Period.                            Period.

Re-Cement Inlays/Onlays,             50%                                60%
Crowns, Bridges and Post and
Core                                 Subject to a 12 month Waiting      Subject to a 12 month Waiting
                                     Period.                            Period.
Limited to those performed more
than 12 months after the initial
insertion.

Sedative Filling                     50%                                60%
Covered as a separate benefit        Subject to a 12 month Waiting      Subject to a 12 month Waiting
only if no other service, other      Period.                            Period.
than x-rays and exam, were done
on the same tooth during the
visit.

Stainless Steel Crowns               50%                                60%
Limited to 1 time per tooth per      Subject to a 12 month Waiting      Subject to a 12 month Waiting
consecutive 60 months. Covered       Period.                            Period.
only when a filling cannot restore
the tooth. Prefabricated esthetic
coated stainless steel crown -
primary tooth, are limited to
primary anterior teeth.




DSCH.IPO.06                                     14
BENEFIT DESCRIPTION &                  NETWORK                            NON-NETWORK
LIMITATION
                                       COPAYMENT                          COPAYMENT
                                       is shown as a percentage of        is shown as a percentage of
                                       Eligible Expenses or is shown as   Eligible Expenses or is shown as
                                       a fixed dollar after applicable    a fixed dollar after applicable
                                       Deductible is satisfied.           Deductible is satisfied.
                                                                          You must also pay the amount of
                                                                          the Dentist's fee, if any, which is
                                                                          greater than the Eligible
                                                                          Expense.

FIXED PROSTHETICS
Replacement of complete dentures, fixed or removable partial dentures, crowns, inlays or onlays
previously submitted for payment under the plan is limited to 1 time per consecutive 60 months from initial
or supplemental placement.

Fixed Partial Dentures (Bridges)       50%                                60%
Limited to 1 time per tooth per        Subject to a 12 month Waiting      Subject to a 12 month Waiting
consecutive 60 months.                 Period.                            Period.

REMOVABLE PROSTHETICS
Replacement of complete dentures, fixed or removable partial dentures, crowns, inlays or onlays
previously submitted for payment under the plan is limited to 1 time per consecutive 60 months from initial
or supplemental placement.

Full Dentures                          50%                                60%
Limited to 1 per consecutive 60        Subject to a 12 month Waiting      Subject to a 12 month Waiting
months. No additional                  Period.                            Period.
allowances for precision or semi-
precision attachments.

Partial Dentures                       50%                                60%
Limited to 1 per consecutive 60        Subject to a 12 month Waiting      Subject to a 12 month Waiting
months. No additional                  Period.                            Period.
allowances for precision or semi-
precision attachments.

Relining and Rebasing Dentures         50%                                60%
Limited to relining/rebasing           Subject to a 12 month Waiting      Subject to a 12 month Waiting
performed more than 6 months           Period.                            Period.
after the initial insertion. Limited
to 1 time per consecutive 12
months.

Tissue Conditioning - Maxillary or     50%                                60%
Mandibular
                                       Subject to a 12 month Waiting      Subject to a 12 month Waiting
Limited to 1 time per consecutive      Period.                            Period.
12 months.




DSCH.IPO.06                                       15
BENEFIT DESCRIPTION &                  NETWORK                            NON-NETWORK
LIMITATION
                                       COPAYMENT                          COPAYMENT
                                       is shown as a percentage of        is shown as a percentage of
                                       Eligible Expenses or is shown as   Eligible Expenses or is shown as
                                       a fixed dollar after applicable    a fixed dollar after applicable
                                       Deductible is satisfied.           Deductible is satisfied.
                                                                          You must also pay the amount of
                                                                          the Dentist's fee, if any, which is
                                                                          greater than the Eligible
                                                                          Expense.

Repairs or Adjustments to Full         50%                                60%
Dentures, Partial Dentures,
Bridges or Crowns                      Subject to a 12 month Waiting      Subject to a 12 month Waiting
                                       Period.                            Period.
Limited to repairs or adjustments
performed more than 12 months
after the initial insertion. Limited
to 1 per consecutive 6 months.

ORTHODONTICS
Orthodontic services are subject to the applicable Waiting Period, satisfaction of any Deductible and any
orthodontic Deductible, and payment of any applicable Copayments.

Orthodontic Services                   50%                                50%
Services or supplies furnished by      Subject to a 12 month Waiting      Subject to a 12 month Waiting
a Dentist to a Dependent under         Period.                            Period.
age 25 in order to diagnose or
correct misalignment of the teeth
or the bite. The extended
coverage provision does not
apply to orthodontic services.

Appliance Therapy, Fixed or            50%                                50%
Removable
                                       Subject to a 12 month Waiting      Subject to a 12 month Waiting
Limited to 1 time per consecutive      Period.                            Period.
60 months. This includes
retainers, habit appliances, and
any fixed or removable
interceptive orthodontic
appliances.

Cephalometric Film                     50%                                50%
Limited to 1 per consecutive 12        Subject to a 12 month Waiting      Subject to a 12 month Waiting
months. Can only be billed for         Period.                            Period.
orthodontics.




DSCH.IPO.06                                       16
                       UNITEDHEALTHCARE DENTAL
                    NOTICE OF PRIVACY PRACTICES
       THIS NOTICE DESCRIBES HOW MEDICAL
    INFORMATION ABOUT YOU MAY BE USED AND
   DISCLOSED AND HOW YOU CAN GET ACCESS TO
       THIS INFORMATION. PLEASE REVIEW IT
                   CAREFULLY.
                                         Effective: April 14, 2003
We* are required by law to protect the privacy of your health information. We are also required to send
you this notice which explains how we may use information about you and when we can give out or
"disclose" that information to others. You also have rights regarding your health information that are
described in this notice.
The terms "information" or "health information" in this notice include any personal information that is
created or received by a health care provider or health plan that related to your physical or mental health
or condition, the provision of health care to you, or the payment for such health care.
We have the right to change our privacy practices. If we do, we will provide the revised notice to you
within 60 days by direct mail or post it on our web site www.uhcspecialtybenefits.com.
      *For purposes of this Notice of Privacy Practices, "we" or "us" refers to the following
      UnitedHealthcare entities: ACN Group of California, Inc.; All Savers Insurance Company;
      AmeriChoice of New Jersey, Inc; AmeriChoice of New York, Inc.; AmeriChoice of Pennsylvania,
      Inc.; Arizona Physicians IPA, In.; Dental Benefit Providers of California, Inc.; Dental benefit
      Providers of Illinois, Inc.; Dental Benefit Providers of Maryland, Inc.; Dental Benefit Providers of
      New Jersey, Inc.; Evercare of Arizona, Inc.; Evercare of Texas, L.L.C.; Fidelity Insurance
      Company; Golden Rule Insurance Company; Great Lakes Health Plan, Inc.; Investors Guaranty
      Life Insurance Company; MAMSI Life and Health Insurance Company; MD-Individual Practice
      Association, Inc.; Midwest Security Life Insurance Company; National Pacific Dental, Inc.; Nevada
      Pacific Dental, Inc.; Optimum Choice, Inc.; Optimum Choice of the Carolinas, Inc.; Optimum
      Choice, Inc. of Pennsylvania; Oxford Health Insurance, Inc.; Oxford Health Plans (CT), Inc.; Oxford
      Health Plans (NJ), Inc.; Oxford Health Plans (NY), Inc.; Pacific Union Dental, Inc.; Rooney Life
      Insurance Company; Spectera, Inc.; Spectera Vision, Inc.; Spectera Vision Services of California,
      Inc.; Unimerica Insurance Company; Unimerica Life Insurance Company of New York; United
      Behavioral Health; United HealthCare of Alabama, Inc.; United HealthCare of Arizona, Inc.; United
      HealthCare of Arkansas, Inc.; United HealthCare of Colorado, Inc.; United HealthCare of Florida,
      Inc.; United HealthCare of Georgia, Inc.; UnitedHealthcare of Illinois, Inc.; United HealthCare of
      Kentucky, Ltd.; United HealthCare of Louisiana, Inc., UnitedHealthcare of the Mid-Atlantic, Inc.;
      United HealthCare of the Midlands, Inc.; United HealthCare of the Midwest, Inc.; United HealthCare
      of Mississippi, Inc.; UnitedHealthcare of New England, Inc.; UnitedHealthcare of New Jersey, Inc.;
      UnitedHealthcare of New York, Inc.; UnitedHealthcare of North Carolina, Inc.; United HealthCare of
      Ohio, Inc.; United HealthCare of Tennessee, Inc.; United HealthCare of Texas, Inc.; United
      HealthCare of Utah; UnitedHealthcare of Wisconsin, Inc.; United HealthCare Insurance Company;
      United HealthCare Insurance Company of Illinois; United HealthCare Insurance Company of New
      York; United HealthCare Insurance Company of Ohio; and U.S. Behavioral Health Plan, California.



                                                 I
How We Use or Disclose Information
We must use and disclose your health information to provide information:

•     To you or someone who has the legal right to act for you (your personal representative);

•     To the Secretary of the Department of Health and Human Services, if necessary, to make sure
      your privacy is protected; and

•     Where required by law.
We have the right to use and disclose health information to pay for your health care and operate our
business. For example, we may use your health information:

•     For Payment of premiums due us and to process claims for health care services you receive.

•     For Treatment. We may disclose health information to your doctors or hospitals to help them
      provide medical care to you.

•     For Health Care Operations. We may use or disclose health information as necessary to operate
      and manage our business and to help manage your health care coverage. For example, we might
      talk to your doctor to suggest a disease management or wellness program that could help improve
      your health.

•     To Plan Sponsors. If your coverage is through an employer group health plan, we may share
      summary health information and enrollment and disenrollment information with the plan sponsor. In
      addition, we may share other health information with the plan sponsor for plan administration if the
      plan sponsor agrees to special restriction on its use and disclosure of the information.

•     For Appointment Reminders. We may use health information to contact you for appointment
      reminders with providers who provide medical care to you.
We may use or disclose your health information for the following purposes under limited circumstances:

•     To Persons Involved With Your Care. We may use or disclose your health information to a
      person involved in your care, such as a family member, when you are incapacitated or in an
      emergency, or when permitted by law.

•     For Public Health Activities such as reporting disease outbreaks.

•     For Reporting Victims of Abuse, Neglect or Domestic Violence to government authorities,
      including a social service or protective service agency.

•     For Health Oversight Activities such as governmental audits and fraud and abuse investigations.

•     For Judicial or Administrative Proceedings such as in response to a court order, search warrant
      or subpoena.

•     For Law Enforcement Purposes such as providing limited information to locate a missing person.

•     To Avoid a Serious Threat to Health or Safety by, for example, disclosing information to public
      health agencies.

•     For Specialized Government Functions such as military and veteran activities, national security
      and intelligence activities, and the protective services for the President and others.

•     For Workers Compensation including disclosures required by state workers compensation laws
      of job-related injuries.




                                                II
•     Provide Information Regarding Decedents. We may disclose information to a coroner or medical
      examiner to identify a deceased person, determine a cause of death, or as authorized by law. We
      may also disclose information to funeral directors as necessary to carry out their duties.
If none of the above reasons apply, then we must get your written authorization to use or disclose
your health information. If a use or disclosure of health information is prohibited or materially limited by
other applicable law, it is our intent to meet the requirements of the more stringent law. In some states,
your authorization may also be required for disclosure of your health information. In many states, your
authorization may be required in order for us to disclose your highly confidential health information, as
described below. Once you give us authorization to release your health information, we cannot guarantee
that the person to whom the information is provided will not disclose the information. You may take back
or "revoke" your written authorization, except if we have already acted based on your authorization. To
revoke an authorization, refer to "Exercising Your Rights" on page 4 of this notice.


Highly Confidential Information
Federal and applicable state laws may require special privacy protections for highly confidential
information about you. "Highly confidential information" may include confidential information under
Federal law governing alcohol and drug abuse information as well as state laws that often protect the
following types of information:

•     HIV/AIDS;

•     Mental health;

•     Genetic tests;

•     Alcohol and drug abuse;

•     Sexually transmitted diseases and reproductive health information; and

•     Child or adult abuse or neglect, including sexual assault.
Attached to this notice is a Summary of State Laws on Use and Disclosure of Certain Types of Medical
Information.


What Are Your Rights
The following are your rights with respect to your health information.

•     You have the right to ask to restrict uses or disclosures of your information for treatment,
      payment, or health care operations. You also have the right to ask to restrict disclosures to family
      members or to others who are involved in your health care or payment for your health care. We
      may also have policies on dependent access that may authorize certain restrictions. Please note
      that while we will try to honor your request and will permit requests consistent with its
      policies, we are not required to agree to any restriction.

•     You have the right to ask to receive confidential communications of information in a different
      manner or at a different place (for example, by sending information to a P.O. box instead of your
      home address).

•     You have the right to see and obtain a copy of health information that may be used to make
      decisions about you such as claims and case or medical management records. You also may
      receive a summary of this health information. You must make a written request to inspect and copy
      your health information. In certain limited circumstances, we may deny your request to inspect and
      copy your health information.




                                                 III
•    You have the right to ask to amend information we maintain about you if you believe the health
     information about you is wrong or incomplete. If we deny your request, you may have a statement
     of your disagreement added to your health information.

•    You have the right to receive an accounting of disclosures of your information made by us
     during the six years prior to your request. This accounting will not include disclosures of
     information: (i) made prior to April 14, 2003; (ii) for treatment, payment, and health care operations
     purposes; (iii) to you or pursuant to your authorization; and (iv) to correctional institutions or law
     enforcement officials; and (v) other disclosures that federal law does not require us to provide an
     accounting.

•    You have the right to a paper copy of this notice. You may ask for a copy of this notice at any
     time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper
     copy of this notice. You may obtain a copy of this notice at our website,
     www.uhcspecialtybenefits.com


Exercising Your Rights
•    Contacting your Health Plan. If you have any questions about this notice or want to exercise any
     of your rights, please call the phone number on your ID card.

•    Filing a Complaint. If you believe your privacy rights have been violated, you may file a complaint
     with us at the following address:
                                            United Healthcare
                                     Customer Service - Privacy Unit
                                             PO Box 740815
                                         Atlanta, GA 30374-0815
You may also notify the Secretary of the U.S. Department of Health and Human Services of your
complaint. We will not take any action against you for filing a complaint.




                                                IV
Financial Information Privacy Notice
We (including our affiliates listed at the bottom of this page)* are committed to maintaining the
confidentiality of your personal financial information. For the purposes of this notice, "personal financial
information" means information, other than health information, about an enrollee or an applicant for health
care coverage that identifies the individual, is not generally publicly available and is collected from the
individual or is obtained in connection with providing health care coverage to the individual.
We collect personal financial information about you from the following sources:

•     Information we receive from you on applications or other forms, such as name, address, age and
      social security number; and

•     Information about your transactions with us, our affiliates or others, such as premium payment
      history.
We do not disclose personal financial information about our enrollees or former enrollees to any third
party, except as required or permitted by law.
We restrict access to personal financial information about you to employees and service providers who
are involved in administering your health care coverage and providing services to you. We maintain
physical, electronic and procedural safeguards that comply with federal standards to guard your personal
financial information.
*For purposes of this Financial Information Privacy Notice, "we" or "us" refers to the entities on the first
page of the Notice of Privacy Practices, plus the following UnitedHealthcare affiliates: ACN Group, Inc.;
ACN Group IPA of New York, Inc.; Alliance Recovery Services, LLC; AmeriChoice Health Services, Inc.;
Behavioral Health Administrators; Continental Plan Services, Inc.; Coordinated Vision Care, Inc.; DBP-
KAI, Inc.; Disability Consulting Group, LLC; DCG Resource Options, LLC; Definity Health Corporation;
Definity Health of New York, Inc.; Dental Benefit Providers, Inc.; Dental Insurance Company of America;
Exante Bank, Inc.; Fidelity Benefit Administrators, Inc.; HealthAllies, Inc.; IBA Self Funded Group, Inc.;
Illinois Pacific Dental, Inc.; Lifemark Corporation; MAMSI Insurance Resources, LLC; Managed Physical
Network, Inc.; Mid Atlantic Medical Services, LLC; Midwest Security Administrators, Inc.; Midwest
Security Care, Inc.; National Benefit Resources, Inc.; NPD Dental Services; NPD Insurance Company,
Inc.; OneNet PPO, LLC; Oxford Benefit Management, Inc.; Oxford Health Plans LLC; Pacific Dental
Benefits; PacifiCare Behavioral Health NY IPA, Inc.; PacifiCare Health Plan Administrators, Inc.;
ProcessWorks, Inc.; Spectera of New York, IPA, Inc.; Uniprise, Inc.; United Behavioral Health of New
York, I.P.A., Inc.; UnitedHealth Advisors, LLC; United HealthCare Services, Inc.; UnitedHealthcare
Services Company of the River Valley, Inc.; United HealthCare Service LLC; United Medical Resources,
Inc.




                                                 V
Summary of State Laws on Use and Disclosure of Certain Types of
Medical Information
This information is intended to provide an overview of state laws that are more stringent than the federal
Health Insurance Portability and Accountability Act (HIPAA) Privacy Rules with respect to the use or
disclosure of protected health information in the categories listed below.

 Sexually Transmitted Diseases and Reproductive Health

 Disclosure of sexually transmitted diseases and       HI, MS, NM, NY, NC, OK, WA, VA
 reproductive health related information may be:
 (1) limited to specified circumstances; and/or (2)
 restricted by the patient.

 Disclosure of sexually transmitted diseases and       NM
 reproductive health information must be
 accompanied by a written statement meeting
 certain requirements.

 There are specific requirements that must be          MS
 followed when an insurer uses or requests
 sexually transmitted disease tests or reproductive
 health information for insurance or underwriting
 purposes.

 Alcohol and Drug Abuse

 Disclosure of alcohol and drug abuse information      GA, HI, KY, MA, NH, OK, VA, WA, WI
 may be: (1) limited to specified circumstances; (2)
 restricted by the patient; and/or (3) prohibited
 under certain circumstances.

 A specific written statement must accompany any       WI
 alcohol and drug abuse information disclosures.

 Specific requirements must be followed when an        KY, VA
 insurer uses or requests drug and alcohol tests or
 information for insurance or underwriting
 purposes.

 Genetic Information

 An authorization is required for each disclosure of   CA, HI, KY, LA, RI, TN
 genetic information.

 Genetic information may be disclosed only under       AZ, CO, FL, GA, HI, IL, MD, MA, MO, NV, NH,
 specific circumstances.                               NJ, NM, NY, OR, TX, VT

 Restrictions apply to (1) the use; and/or (2) the     CO, GA, IL, NV, NJ, NM, OR, VT, WY
 retention of genetic information.

 Specific requirements must be followed when an        FL, IL, IN, LA, NV, WY
 insurer uses or requests a genetic test for
 insurance or underwriting purposes.




                                                 VI
HIV/AIDS

Disclosure of HIV/AIDS related information may          AZ, AR, CA, CO, CT, DE, DC, FL, GA, HI, IL,
only be: (1) limited to specific circumstances;         IN, IA, KY, ME, MA, MI, NH, NJ, NM, NY, NC,
and/or (2) restricted by the patient.                   OH, OK, OR, PA, TX, UT, VT, VA, WA, WV, WI

A specific written statement must accompany any         AZ, CT, KY, NM, OR, PA, WV
HIV/AIDS related information.

Certain restrictions apply to the retention of          MA, NH
HIV/AIDS related information.

Specific requirements must be followed when an          AR, DE, FL, IA, MA, NH, PA, UT, VA, VT, WA,
insurer uses or requests an HIV/AIDS test for           WV
insurance or underwriting purposes.

Improper disclosure may be subject to penalties.        DE

Disclosure to the individual and/or designated          MA, NH
physician may be required.

Mental Health

Disclosure of mental health information may be:         AL, AZ, CA, CO, CT, DC, FL, GA, HI, ID, IL, IN,
(1) limited to specific circumstances; (2) restricted   IA, KY, ME, MA, MD, MI, MN, NM, NY, OK, PA,
by the patient; and/or (3) prohibited or prevented      TN, TX, VT, VA, WA, WV, WI
under certain circumstances.

A specific written statement must accompany any         WI
mental health information disclosures.

Specific requirements must be followed when an          IA, KY, ME, MA, NM, TN, VA
insurer uses or requests mental health information
for insurance or underwriting purposes.

Child or Adult Abuse

Abuse related information may only be disclosed         AL, LA, NM, TN, UT, VA, WI
under specific circumstances.




                                                 VII
     Continuation Coverage under Federal Law (COBRA)
Much of the language in this section comes from the federal law that governs continuation coverage. You
should call your enrolling group's plan administrator if you have questions about your right to continue
coverage.
In order to be eligible for continuation coverage under federal law, you must meet the definition of a
"Qualified Beneficiary". A Qualified Beneficiary is any of the following persons who was covered under the
policy on the day before a qualifying event:

•     A subscriber.

•     A subscriber's enrolled dependent, including with respect to the subscriber's children, a child born
      to or placed for adoption with the subscriber during a period of continuation coverage under federal
      law.

•     A subscriber's former spouse.


Qualifying Events for Continuation Coverage under Federal Law
(COBRA)
If the coverage of a Qualified Beneficiary would ordinarily terminate due to one of the following qualifying
events, then the Qualified Beneficiary is entitled to continue coverage. The Qualified Beneficiary is
entitled to elect the same coverage that she or he had on the day before the qualifying event.
The qualifying events with respect to an employee who is a Qualified Beneficiary are:
A.    Termination of the subscriber from employment with the enrolling group, for any reason other than
      gross misconduct.
B.    Reduction in the subscriber's hours of employment.
With respect to a subscriber's spouse or dependent child who is a Qualified Beneficiary, the qualifying
events are:
A.    Termination of the subscriber from employment with the enrolling group, for any reason other than
      the subscriber's gross misconduct.
B.    Reduction in the subscriber's hours of employment.
C.    Death of the subscriber.
D.    Divorce or legal separation of the subscriber.
E.    Loss of eligibility by an enrolled dependent who is a child.
F.    Entitlement of the subscriber to Medicare benefits.
G.    The enrolling group filing for bankruptcy, under Title 11, United States Code. This is also a
      qualifying event for any retired subscriber and his or her enrolled dependents if there is a
      substantial elimination of coverage within one year before or after the date the bankruptcy was
      filed.




                                                VIII
Notification Requirements and Election Period for Continuation
Coverage under Federal Law (COBRA)

Notification Requirements for Qualifying Event
The subscriber or other Qualified Beneficiary must notify the enrolling group's plan administrator within 60
days of the latest of the date of the following events:

•     The subscriber's divorce or legal separation, or an enrolled dependent's loss of eligibility as an
      enrolled dependent.

•     The date the Qualified Beneficiary would lose coverage under the policy.

•     The date on which the Qualified Beneficiary is informed of his or her obligation to provide notice
      and the procedures for providing such notice.
The subscriber or other Qualified Beneficiary must also notify the enrolling group's plan administrator
when a second qualifying event occurs, which may extend continuation coverage.
If the subscriber or other Qualified Beneficiary fails to notify the enrolling group's plan administrator of
these events within the 60 day period, the plan administrator is not obligated to provide continued
coverage to the affected Qualified Beneficiary. If a subscriber is continuing coverage under federal law,
the subscriber must notify the enrolling group's plan administrator within 60 days of the birth or adoption
of a child.


Notification Requirements for Disability Determination or Change in Disability
Status
The subscriber or other Qualified Beneficiary must notify the enrolling group's plan administrator as
described under "Terminating Events for Continuation Coverage under Federal Law (COBRA),"
subsection A. below.
The notice requirements will be satisfied by providing written notice to the enrolling group's plan
administrator at the address stated in the ERISA Statement. The contents of the notice must be such that
the plan administrator is able to determine the covered employee and Qualified Beneficiary or
beneficiaries, the qualifying event or disability, and the date on which the qualifying event occurred.
None of the above notice requirements will be enforced if the subscriber or other Qualified Beneficiary is
not informed of his or her obligations to provide such notice.
After providing notice to the enrolling group's plan administrator, the Qualified Beneficiary shall receive
the continuation coverage and election notice. Continuation coverage must be elected by the later of 60
days after the qualifying event occurs; or 60 days after the Qualified Beneficiary receives notice of the
continuation right from the plan administrator.
The Qualified Beneficiary's initial premium due to the plan administrator must be paid on or before the
45th day after electing continuation.
The Trade Act of 2002 amended COBRA to provide for a special second 60-day COBRA election period
for certain employees who have experienced a termination or reduction of hours and who lose group
health plan coverage as a result. The special second COBRA election period is available only to a very
limited group of individuals: generally, those who are receiving trade adjustment assistance (TAA) or
'alternative trade adjustment assistance' under a federal law called the Trade Act of 1974. These
employees are entitled to a second opportunity to elect COBRA coverage for themselves and certain
family members (if they did not already elect COBRA coverage), but only within a limited period of 60
days from the first day of the month when an individual begins receiving TAA (or would be eligible to
receive TAA but for the requirement that unemployment benefits be exhausted) and only during the six
months immediately after their group health plan coverage ended.

                                                 IX
If you qualify or may qualify for assistance under the Trade Act of 1974, contact the enrolling group for
additional information. You must contact the enrolling group promptly after qualifying for assistance under
the Trade Act of 1974 or you will lose your special COBRA rights. COBRA coverage elected during the
special second election period is not retroactive to the date that plan coverage was lost but begins on the
first day of the special second election period.


Terminating Events for Continuation Coverage under Federal Law
(COBRA)
Continuation under the policy will end on the earliest of the following dates:
A.    Eighteen months from the date of the qualifying event, if the Qualified Beneficiary's coverage would
      have ended because the subscriber's employment was terminated or hours were reduced (i.e.,
      qualifying event A.).
      If a Qualified Beneficiary is determined to have been disabled under the Social Security Act at any
      time within the first 60 days of continuation coverage for qualifying event A. then the Qualified
      Beneficiary may elect an additional eleven months of continuation coverage (for a total of twenty-
      nine months of continued coverage) subject to the following conditions:
            Notice of such disability must be provided within the latest of 60 days after:
            the determination of the disability; or
            the date of the qualifying event; or
            the date the Qualified Beneficiary would lose coverage under the policy; and
            in no event later than the end of the first eighteen months.
            The Qualified Beneficiary must agree to pay any increase in the required premium for the
             additional eleven months.
            If the Qualified Beneficiary who is entitled to the eleven months of coverage has non-
             disabled family members who are also Qualified Beneficiaries, then those non-disabled
             Qualified Beneficiaries are also entitled to the additional eleven months of continuation
             coverage.
      Notice of any final determination that the Qualified Beneficiary is no longer disabled must be
      provided within 30 days of such determination. Thereafter, continuation coverage may be
      terminated on the first day of the month that begins more than 30 days after the date of that
      determination.
B.    Thirty-six months from the date of the qualifying event for an enrolled dependent whose coverage
      ended because of the death of the subscriber, divorce or legal separation of the subscriber, or loss
      of eligibility by an enrolled dependent who is a child (i.e. qualifying events C., D., or E.).
C.    With respect to Qualified Beneficiaries, and to the extent that the subscriber was entitled to
      Medicare prior to the qualifying event:
            Eighteen months from the date of the subscriber's Medicare entitlement; or
            Thirty-six months from the date of the subscriber's Medicare entitlement, if a second
             qualifying event (that was due to either the subscriber's termination of employment or the
             subscriber's work hours being reduced) occurs prior to the expiration of the eighteen
             months.
D.    With respect to Qualified Beneficiaries, and to the extent that the subscriber became entitled to
      Medicare subsequent to the qualifying event:


                                                    X
          Thirty-six months from the date of the subscriber's termination from employment or work
           hours being reduced (first qualifying event) if:
          The subscriber's Medicare entitlement occurs within the eighteen month continuation period;
           and
          If, absent the first qualifying event, the Medicare entitlement would have resulted in a loss of
           coverage for the Qualified Beneficiary under the group health plan.
E.   The date coverage terminates under the policy for failure to make timely payment of the premium.
F.   The date, after electing continuation coverage, that coverage is first obtained under any other
     group health plan. If such coverage contains a limitation or exclusion with respect to any pre-
     existing condition, continuation shall end on the date such limitation or exclusion ends. The other
     group health coverage shall be primary for all health services except those health services that are
     subject to the pre-existing condition limitation or exclusion.
G.   The date, after electing continuation coverage, that the Qualified Beneficiary first becomes entitled
     to Medicare, except that this shall not apply in the event that coverage was terminated because the
     enrolling group filed for bankruptcy, (i.e. qualifying event G.). If the Qualified Beneficiary was
     entitled to continuation because the enrolling group filed for bankruptcy, (i.e. qualifying event G.)
     and the retired subscriber dies during the continuation period, then the other Qualified Beneficiaries
     shall be entitled to continue coverage for thirty-six months from the date of the subscriber's death.
H.   The date the entire policy ends.
I.   The date coverage would otherwise terminate under the policy.




                                               XI
   Statement of Employee Retirement Income Security
               Act of 1974 (ERISA) Rights
As a participant in the plan, you are entitled to certain rights and protections under the Employee
Retirement Income Security Act of 1974 (ERISA).


Receive Information About Your Plan and Benefits
You are entitled to examine, without charge, at the Plan Administrator's office and at other specified
locations, such as worksites and union halls, all documents governing the plan, including insurance
contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500
Series) filed by the plan with the U.S. Department of Labor and available at the Public Disclosure Room
of the Employee Benefits Security Administration.
You are entitled to obtain, upon written request to the Plan Administrator, copies of documents governing
the operation of the plan, including insurance contracts and collective bargaining agreements, and copies
of the latest annual report (Form 5500 Series) and updated Summary Plan Description. The Plan
Administrator may make a reasonable charge for the copies.
You are entitled to receive a summary of the plan's annual financial report. The Plan Administrator is
required by law to furnish each participant with a copy of the summary annual report.


Continue Group Health Plan Coverage
You are entitled to continue health care coverage for yourself, spouse or dependents if there is a loss of
coverage under the plan as a result of a qualifying event. You or your dependents may have to pay for
such coverage. The Plan Sponsor is responsible for providing you notice of your COBRA continuation
rights. Review this Summary Plan Description and the documents governing the plan on the rules
governing your COBRA continuation coverage rights.


Prudent Actions by Plan Fiduciaries
In addition to creating rights for plan participants, ERISA imposes duties upon the people who are
responsible for the operation of the employee benefit plan. The people who operate your plan, called
"fiduciaries" of the plan, have a duty to do so prudently and in the interest of you and other plan
participants and beneficiaries. No one, including your employer, your union, or any other person may fire
you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or
exercising your rights under ERISA.


Enforce Your Rights
If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why
this was done, to obtain copies of documents relating to the decision without charge, and to appeal any
denial, all within certain time schedules. Under ERISA, there are steps you can take to enforce the above
rights. For instance, if you request a copy of plan documents or the latest annual report from the plan and
do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may
require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the
materials, unless the materials were not sent because of reasons beyond the control of the Plan
Administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, you may file
suit in a state or Federal court. In addition, if you disagree with the plan's decision or lack thereof
concerning the qualified status of a domestic relations order or a medical child support order, you may file
suit in Federal court. If it should happen that plan fiduciaries misuse the plan's money, or if you are
discriminated against for asserting your rights, you may seek assistance from the U.S. Department of
Labor, or you may file suit in a Federal court. The court will decide who should pay court costs and legal

                                                 XII
fees. If you are successful the court may order the person you have sued to pay these costs and fees. If
you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is
frivolous.


Assistance with Your Questions
If you have any questions about your plan, you should contact the Plan Administrator. If you have any
questions about this statement or about your rights under ERISA, or if you need assistance in obtaining
documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits
Security Administration, United States Department of Labor listed in your telephone directory or the
Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S.
Department of Labor, 200 Constitution Avenue, N.W., Washington, D.C. 20210. You may also obtain
certain publications about your rights and responsibilities under ERISA by calling the publication hotline of
the Employee Benefits Security Administration.




                                                XIII
ERISA Statement
If the Enrolling Group is subject to ERISA, the following information applies to you.


Summary Plan Description
Name of Plan: The School District of Palm Beach County Welfare Benefit Plan
Name, Address and Telephone Number of Plan Sponsor and Named Fiduciary:
                                The School District of Palm Beach County
                                      3370 Forest Hill Boulevard
                                                  A-103
                                      West Palm Beach, FL 33406
                                            (561) 434-8556
The Plan Sponsor retains all fiduciary responsibilities with respect to the Plan except to the extent the
Plan Sponsor has delegated or allocated to other persons or entities one or more fiduciary responsibility
with respect to the Plan.
Claims Fiduciary:
                                  United HealthCare Insurance Company
Employer Identification Number (EIN): 59-6000783
IRS Plan Number: 501
Effective Date of Plan: The effective date of the Plan is January 1, 2010
Type of Plan: Dental care coverage plan
Name, business address, and business telephone number of Plan Administrator:
                                The School District of Palm Beach County
                                      3370 Forest Hill Boulevard
                                                  A-103
                                      West Palm Beach, FL 33406
                                            (561) 431-8556
Type of Administration of the Plan:
Benefits are paid pursuant to the terms of a group health policy issued and insured by:
                                  United HealthCare Insurance Company
                                         450 Columbus Boulevard
                                         Hartford, CT 06115-0450
The Plan is administered on behalf of the Plan Administrator by United HealthCare Insurance Company
pursuant to the terms of the group Policy. United HealthCare Insurance Company provides administrative
services for the Plan including claims processing, claims payment, and handling appeals.
Person designated as agent for service of legal process: Plan Administrator:
Source of contributions and funding under the Plan: There are no contributions to the Plan. Any
required employee contributions are used to partially reimburse the Plan Sponsor for Premiums under the
Plan. Benefits under the Plan are funded by the payment of Premium required by the group Policy.



                                                XIV
Method of calculating the amount of contribution: Employee-required contributions to the Plan
Sponsor are the employee's share of costs as determined by Plan Sponsor. From time to time, the Plan
Sponsor will determine the required employee contributions for reimbursement to the Plan Sponsor and
distribute a schedule of such required contributions to employees.
Date of the end of the year for purposes of maintaining Plan's fiscal records:
Plan year shall be a twelve month period ending December 31.
Determinations of Qualified Medical Child Support Orders. The plan's procedures for handling
qualified medical child support orders are available without charge upon request to the Plan
Administrator.




                                             XV
718606 - 01/23/2010

								
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